Avortement au Maroc et virage au drame : femmes et professionnels de santé en parlent ! Une étude transversale mixte à Agadir.

RésuméLes avortements à risque constituent une problématique majeure de santé publique, responsable de la mortalité et de la morbidité maternelles et absorbant les ressources des systèmes de santé publique à l'échelle mondiale. Malgré l'ampleur très probable du problème de l'avortement non sécurisé au Maroc, peu de données sont accessibles sur cette question. Cette recherche vise à analyser la situation de l'avortement du point de vue des femmes et des professionnels de santé dans la préfecture d'Agadir Idaoutanane au Sud du Maroc. Nous avons conduit une étude transversale mixte. De janvier à septembre 2018, 266 femmes ont été recrutées pour répondre à un questionnaire, et 45 entretiens avec les femmes et les professionnels de la santé impliqués dans la santé sexuelle et reproductive (SSR) ont été menés. Nous avons procédé à une analyse descriptive des données quantitatives et à une analyse de contenu thématique des données recueillies par les entretiens individuels. Les résultats de l'étude révèlent que les avortements sont la conjugaison de plusieurs facteurs multidimensionnels. Le manque d'informations en SSR et l'échec de la contraception sont les facteurs majeurs de grossesses non désirées. L'avortement provoqué est un sujet tabou, fortement stigmatisant, portant à l'image sociale de la personne. L'accessibilité aux services d'avortement est marquée de grandes disparités et de trajectoires différentes. Cette étude apporte une contribution à l'analyse du phénomène de l'avortement au Maroc et appelle à une action politique urgente sur plusieurs niveaux: l'accès aux programmes d'éducation sexuelle et à la contraception appropriée, l'élargissement des indications d'avortement préconisées dans le projet de loi, la mise en place des stratégies de lutte contre la stigmatisation de l'avortement par les professionnels de santé et l'accès à des soins post-avortement de haute qualité.

Implementation of a new program of gestational diabetes screening and management in Morocco: a qualitative exploration of health workers' perceptions.

BACKGROUND: Gestational diabetes mellitus (GDM) is associated with an increased risk for a future type 2 diabetes mellitus in women and their children. As linkage between maternal health and non-communicable diseases, antenatal care plays a key role in the primary and secondary prevention of GDM associated adverse outcomes. While implementing a locally adapted GDM screening and management approach through antenatal care services at the primary level of care, we assessed its acceptability by the implementing health care providers. METHODS: As part of a larger implementation effectiveness study assessing a decentralized gestational diabetes screening and management approach in the prefecture of Marrakech and the rural district of Al Haouz in Morocco, we conducted four focus group discussions with 29 primary health care providers and seven in-depth interviews with national and regional key informants. After transcription of data, we thematically analyzed the data using a combined deductive and inductive approach. RESULTS: The intervention of screening and managing women with gestational diabetes added value to existing antenatal care services but presented an additional workload for first line health care providers. An existing lack of knowledge about gestational diabetes in the community and among private health care physicians required of public providers to spend more time on counselling women. Nurses had to adapt recommendations on diet to the socio-economic context of patients. Despite the additional task, especially nurses and midwives felt motivated by their gained capacity to detect and manage gestational diabetes, and to take decisions on treatment and follow-up. CONCLUSIONS: Detection and initial management of gestational diabetes is an acceptable strategy to extend the antenatal care service offer in Morocco and to facilitate service access for affected pregnant women. Despite its additional workload, gestational diabetes management can contribute to the professional motivation of primary level health care providers. TRIAL REGISTRATION: clinicaltrials.gov; NCT02979756.

Detection and initial management of gestational diabetes through primary health care services in Morocco: An effectiveness-implementation trial.

BACKGROUND: Gestational Diabetes Mellitus (GDM) testing and management in Morocco is associated with delays resulting in late commencement of treatment. To reduce delays and to increase access of women to GDM care, a country-adapted intervention targeting primary health care providers was designed to test the hypothesis that detection and initial management of GDM at the primary level of care improves newborn outcomes in terms of lower birthweights and less cases of macrosomia and impacts on maternal weight gain, glucose balance and pregnancy outcomes. MATERIALS AND METHODS: We conducted a cluster randomized controlled trial in two districts of Morocco. In each district, 10 health centers were randomly selected to serve either as intervention or control sites. Pregnant women attending antenatal care in the study facilities were eligible to participate. At the intervention sites, women were offered GDM screening by capillary glucose testing following International Association of Diabetes in Pregnancy Study Groups/WHO criteria. Women diagnosed with GDM received counselling on nutrition and exercise and were followed up through their health center whereas at control facilities routine practice was applied. Primary outcome was birthweight and secondary outcomes maternal weight gain, glucose control and pregnancy complications. We further assessed GDM prevalence in the intervention arm. Statistical analysis was performed on 210 recruited women. Continuous variables were reported using means while categorical variables using frequencies with tests of independence applying chi-squared tests. Differences of outcome variables between the two groups were estimated by mixed-effects regression models and effect sizes adjusted for confounders. The trial is registered under NCT02979756 at ClinicalTrials.gov. RESULTS: GDM prevalence reached 23.7% in Marrakech. Birthweight in the intervention group was 147grams lower than in the control group (p = 0.08) as was the proportion of macrosomes (3.5% versus 18.4%; p< 0.001). In the intervention arm, women did two times more follow-ups than at control sites (p = 0.001) and mean follow-up intervals were shorter (11.3 days versus 18.7 days; p < 0.001). Overall, 30% more fasting blood sugar values were balanced (p = 0.005) and mean weekly maternal weight gain 49 grams lower (p = 0.032) in the intervention group. More women from control facilities had a delivery complication whereas more newborn complications were observed in women from intervention facilities. No difference between the two groups existed regarding mode of delivery and mean gestational age at delivery. One of the main limitations of the study was the Hawthorn-effect at control sites that might have led to an underestimation of the effect size. CONCLUSION: A high GDM prevalence in Morocco calls for a context-adapted screening and management approach to enable early interventions. GDM detection and care through antenatal care at primary health facilities may have positively impacted on newborn birthweight but findings are inconclusive. Results of this study will contribute to the decision on a potential upscaling of the intervention in Morocco. Future research could examine long term metabolic changes including diabetes type 2 in the cohort of women and their children.

Knowledge and practice related to gestational diabetes among primary health care providers in Morocco: Potential for a defragmentation of care?

INTRODUCTION: The objective of this study was to assess knowledge and practices of general practitioners, nurses and midwives working at primary health care facilities in Morocco regarding screening and management of gestational diabetes (GDM). METHODS: Structured interviews with 100 doctors, midwives and nurses at 44 randomly selected public health care centers were conducted in Marrakech and Al Haouz. All data were descriptively analyzed. Ethical approval for the study was granted by the institutional review boards in Belgium and Morocco. RESULTS: Public primary health care providers have a basic understanding of gestational diabetes but screening and management practices are not uniform. Although 56.8% of the doctors had some pre-service training on gestational diabetes, most nurses and midwives lack such training. After diagnosing GDM, 88.5% of providers refer patients to specialists, only 11.5% treat them as outpatients. DISCUSSION: Updating knowledge and skills of providers through both pre- and in-service-training needs to be supported by uniform national standards enabling first line health care workers to manage women with GDM and thus increase access and provide a continuity in care. Findings of this study will be used to pilot a model of GDM screening and initial management through the primary level of care.

Improving detection and initial management of gestational diabetes through the primary level of care in Morocco: protocol for a cluster randomized controlled trial.

BACKGROUND: Morocco is facing a growing prevalence of diabetes and according to latest figures of the World Health Organization, already 12.4% of the population are affected. A similar prevalence has been reported for gestational diabetes (GDM) and although it is not yet high on the national agenda, immediate and long-term complications threaten the health of mothers and future generations. A situational analysis on GDM conducted in 2015 revealed difficulties in access to screening and delays in receiving appropriate care. This implementation study has as objective to evaluate a decentralized GDM detection and management approach through the primary level of care and assess its potential for scaling up. METHODS: We will conduct a hybrid effectiveness-implementation research using a cluster randomized controlled trial design in two districts of Morocco. Using the health center as unit of randomization we randomly selected 20 health centers with 10 serving as intervention and 10 as control facilities. In the intervention arm, providers will screen pregnant women attending antenatal care for GDM by capillary glucose testing during antenatal care. Women tested positive will receive nutritional counselling and will be followed up through the health center. In the control facilities, screening and initial management of GDM will follow standard practice. Primary outcome will be birthweight with weight gain during pregnancy, average glucose levels and pregnancy outcomes including mode of delivery, presence or absence of obstetric or newborn complications and the prevalence of GDM at health center level as secondary outcomes. Furthermore we will assess the quality of life /care experienced by the women in both arms. Qualitative methods will be applied to evaluate the feasibility of the intervention at primary level and its adoption by the health care providers. DISCUSSION: In Morocco, gestational diabetes screening and its initial management is fragmented and coupled with difficulties in access and treatment delays. Implementation of a strategy that enables detection, management and follow-up of affected women at primary health care level is expected to positively impact on access to care and medical outcomes. TRIAL REGISTRATION: The trial has been registered on clininicaltrials.gov ; identifier NCT02979756 ; retrospectively registered 22 November 2016.

Maternal and Child Health Services in the Context of the Ebola Virus Disease: Health Care Workers' Knowledge, Attitudes and Practices in Rural Guinea.

The objective of this study was to document maternal and child health care workers' knowledge, attitudes and practices on service delivery before, during and after the 2014 EVD outbreak in rural Guinea. We conducted a descriptive cross-sectional study in ten health districts between October and December 2015, using a standardized self-administered questionnaire. Overall 299 CHWs (94% response rate) participated in the study, including nurses/health technicians (49%), midwives (23%), managers (16%) and physicians (12%). Prior to the EVD outbreak, 87% of CHWs directly engaged in managing febrile cases within the facility, while the majority (89% and 63%) referred such cases to another facility and/or EVD treatment centre during and after the EVD outbreak, respectively. Compared to the period before the EVD outbreak when approximately half of CHWs (49%) reported systematically measuring body temperature prior to providing any care to patients, most CHWs reported doing so during (98%) and after the EVD outbreak (88%). The main challenges encountered were the lack of capacity to screen for EVD cases within the facility (39%) and the lack of relevant equipment (10%). The majority (91%) of HCWs reported a decrease in the use of services during the EVD outbreak while an increase was reported by 72% of respondents in the period following the EVD outbreak. Infection prevention and control measures established during the EVD outbreak have substantially improved self-reported provider practices for maternal and child health services in rural Guinea. However, more efforts are needed to maintain and sustain the gain achieved.

Maternal and child health services in the context of the ebola virus disease: health care workers' knowledge, attitudes and practices in rural Guinea

The objective of this study was to document maternal and child health care workers' knowledge, attitudes and practices on service delivery before, during and after the 2014 EVD outbreak in rural Guinea. We conducted a descriptive cross-sectional study in ten health districts between October and December 2015, using a standardized self-administered questionnaire. Overall 299 CHWs (94% response rate) participated in the study, including nurses/health technicians (49%), midwives (23%), managers (16%) and physicians (12%). Prior to the EVD outbreak, 87% of CHWs directly engaged in managing febrile cases within the facility, while the majority (89% and 63%) referred such cases to another facility and/or EVD treatment centre during and after the EVD outbreak, respectively. Compared to the period before the EVD outbreak when approximately half of CHWs (49%) reported systematically measuring body temperature prior to providing any care to patients, most CHWs reported doing so during (98%) and after the EVD outbreak (88%). The main challenges encountered were the lack of capacity to screen for EVD cases within the facility (39%) and the lack of relevant equipment (10%). The majority (91%) of HCWs reported a decrease in the use of services during the EVD outbreak while an increase was reported by 72% of respondents in the period following the EVD outbreak. Infection prevention and control measures established during the EVD outbreak have substantially improved self-reported provider practices for maternal and child health services in rural Guinea. However, more efforts are needed to maintain and sustain the gain achieved

"Why screen if we cannot follow-up and manage?" Challenges for gestational diabetes screening and management in low and lower-middle income countries: results of a cross-sectional survey.

BACKGROUND: The prevalence of gestational diabetes (GDM) in low and lower middle income countries (LLMIC) is increasing. Despite its associated short and long term complications for mothers and their newborns, there is a lack of knowledge about how to detect and manage GDM. The objective of our study was to identify the challenges that first line healthcare providers in LLMIC face in screening and management of GDM. METHODS: We conducted a cross-sectional survey of key informants from 40 low and lower-middle income countries in Africa, South-Asia and Latin-America by sending out questionnaires to 182 gynecologists, endocrinologists and medical doctors. Sixty-seven respondents from 26 LLMIC provided information on the challenges they encounter. Data was thematically analyzed and revealed eight overarching themes, including guidelines; human resources; access; costs; availability of services, equipment and drugs; patient and community factors; and collaboration and communication. RESULTS: Unavailability of guidelines combined with lack of knowledge about GDM on the part of both providers and patients poses a substantial barrier to detection and management of GDM, leading to deficiencies in screening and counseling. Limited access to regular monitoring and follow-up care as a result of distance and costs, in particular with respect to additional expenses related to specific tests and changes in diet were identified as important challenges. Services were not available at all levels nor was adequate testing equipment. Patient factors included lack of motivation and compliance with the recommended therapy. Respondents also highlighted the lack of communication and collaboration between different specialists and treatment delays as a result of patients being seen by multiple providers. CONCLUSIONS: Providers from LLMIC face various challenges related to screening and managing GDM. Policy makers need to address these challenges by strengthening their health care system as a whole and by assuring that non-communicable diseases are better integrated into the existing packages of free or subsidized maternal health care.

Detection and Management of Diabetes during Pregnancy in Low Resource Settings: Insights into Past and Present Clinical Practices.

Background. Timely and adequate treatment is important to limit complications of diabetes affecting pregnancy, but there is a lack of knowledge on how these women are managed in low resource settings. Objective. To identify modalities of gestational diabetes detection and management in low and lower middle income countries. Methods. We conducted a scoping review of published literature and searched the databases PubMed, Web of Science, Embase, and African Index Medicus. We included all articles published until April 24, 2016, containing information on clinical practices of detection and management of gestational diabetes irrespective of publication date or language. Results. We identified 23 articles mainly from Asia and sub-Saharan Africa. The majority of studies were conducted in large tertiary care centers and hospital admission was reported in a third of publications. Ambulatory follow-up was generally done by weekly to fortnightly visits, whereas self-monitoring of blood glucose was not the norm. The cesarean section rate for pregnancies affected by diabetes ranged between 20% and 89%. Referral of newborns to special care units was common. Conclusion. The variety of reported provider practices underlines the importance of promoting latest consensus guidelines on GDM screening and management and the dissemination of information regarding their implementation.

Diagnosis a posteriori? Assessing gestational diabetes screening and management in Morocco.

BACKGROUND: In Morocco, gestational diabetes affects 1 in 10 pregnant women, but knowledge about screening and management practices outside university settings is limited. OBJECTIVE: To provide a comprehensive picture about the current situation of screening and management of gestational diabetes at different levels of care and to highlight existing challenges. DESIGN: We conducted a descriptive mixed methods study in the districts of Al Haouz and Marrakech by using both quantitative and qualitative methods, including document reviews of 369 antenatal cards and 299 hospital files, health facility inventories related to resource availability, 20 key informant interviews as well as focus group discussions with 32 pregnant women and exit interviews with 122 antenatal care (ANC) clients. Quantitative data were descriptively analyzed using STATA Version 13, whereas qualitative data were thematically analyzed using NVIVO Version 10. RESULTS: The findings revealed that sensitization of women about gestational diabetes is low, and only 34.4% have ever heard about it before attending ANC. Fasting blood sugar is used for screening, and women are sent to external laboratories for testing. A fasting blood sugar of 0.92 g/l and above was documented in 12.3% of all antenatal cards examined. Women diagnosed with gestational diabetes are usually referred to a specialist despite general practitioners at health center level being responsible for the management of non-pregnant diabetic patients. CONCLUSIONS: Decentralization of screening for gestational diabetes and initial management of uncomplicated cases at the primary level of care could ease access to care and reduce the number of mothers who are diagnosed after a complication occurred.

Pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa: Scoping Review.

OBJECTIVE: To synthesise the evidence on pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa and to identify the existing knowledge gaps. METHODS: A scoping review of studies reporting on pregnancy and childbirth in women who underwent repair for obstetric fistula in sub-Saharan Africa was conducted. We searched relevant articles published between 1 January 1970 and 31 March 2016, without methodological or language restrictions, in electronic databases, general Internet sources and grey literature. RESULTS: A total of 16 studies were included in the narrative synthesis. The findings indicate that many women in sub-Saharan Africa still desire to become pregnant after the repair of their obstetric fistula. The overall proportion of pregnancies after repair estimated in 11 studies was 17.4% (ranging from 2.5% to 40%). Among the 459 deliveries for which the mode of delivery was reported, 208 women (45.3%) delivered by elective caesarean section (CS), 176 women (38.4%) by emergency CS and 75 women (16.3%) by vaginal delivery. Recurrence of fistula was a common maternal complication in included studies while abortions/miscarriage, stillbirths and neonatal deaths were frequent foetal consequences. Vaginal delivery and emergency C-section were associated with increased risk of stillbirth, recurrence of the fistula or even maternal death. CONCLUSION: Women who get pregnant after repair of obstetric fistula carry a high risk for pregnancy complications. However, the current evidence does not provide precise estimates of the incidence of pregnancy and pregnancy outcomes post-repair. Therefore, studies clearly assessing these outcomes with the appropriate study designs are needed.

Determinants and trends in health facility-based deliveries and caesarean sections among married adolescent girls in Bangladesh.

OBJECTIVE: To identify the determinants and measure the trends in health facility-based deliveries and caesarean sections among married adolescent girls in Bangladesh. METHODS: In order to measure the trends in health facility-based deliveries and caesarean sections, Bangladesh Demographic Health Survey (BDHS) data sets were analysed (BDHS; 1993-1994, 1996-1997, 1999-2000, 2004, 2007, 2011). The BDHS 2011 data sets were analysed to identify the determinants of health facility-based deliveries and caesarean sections. A total of 2813 adolescent girls (aged 10-19 years) were included for analysis. Bivariate and multivariate analyses were performed. RESULTS: Health facility-based deliveries have continuously increased among adolescents in Bangladesh over the past two decades from 3% in 1993-1994 to 24.5% in 2011. Rates of population-based and facility-based caesarean sections have increased linearly among all age groups of women including adolescents. Although the country's overall (population-based) caesarean section rate among adolescents was within acceptable range (11.6%), a rate of nearly 50% health facility level caesarean sections among adolescent girls is alarming. Among adolescent girls, use of antenatal care (ANC) appeared to be the most important predictor of health facility-based delivery (OR: 4.04; 95% CI 2.73 to 5.99), whereas the wealth index appeared as the most important predictor of caesarean sections (OR: 5.7; 95% CI 2.74 to 12.1). CONCLUSIONS: Maternal health-related interventions should be more targeted towards adolescent girls in order to encourage them to access ANC and promote health facility-based delivery. Rising trends of caesarean sections require further investigation on indication and provider-client-related determinants of these interventions among adolescent girls in Bangladesh.

A snapshot of current gestational diabetes management practices from 26 low-income and lower-middle-income countries.

OBJECTIVE: To identify screening and management practices for gestational diabetes mellitus (GDM) in low-income and lower-middle-income countries. METHODS: A cross-sectional survey was conducted between November 12, 2014 and May 11, 2015. Questionnaires were distributed to gynecologists, endocrinologists, and medical doctors who were representatives of national professional societies or were involved in providing care to patients with GDM in low-income or lower-middle-income countries in Africa, South Asia, and Latin America. The data were descriptively analyzed. RESULTS: Questionnaires were sent to 182 individuals and 77 healthcare providers from 26 countries completed the survey. The results demonstrated high diversity in screening and management practices. Only 52 (68%) participants reported that any guidelines were available in their setting. Management of GDM was found to take place mainly at the tertiary level and reported practices, including the frequency of post-diagnosis follow-up, modalities of glucose surveillance, and treatment and practices surrounding delivery, varied and did not always reflect the most recent evidence. CONCLUSION: Attempts to ensure greater adherence to latest consensus guidelines are required, and should be accompanied by systemic changes to improve the detection and management of GDM at primary- and secondary-level healthcare facilities to facilitate patient access to GDM screening and treatment.

Factors associated with loss to follow-up in women undergoing repair for obstetric fistula in Guinea.

OBJECTIVES: To analyse the trend of loss to follow-up over time and identify factors associated with women being lost to follow-up after discharge in three fistula repair hospitals in Guinea. METHODS: This retrospective cohort study used data extracted from medical records of fistula repairs conducted from 1 January 2007 to 30 September 2013. A woman was considered lost to follow-up if she did not return within 4 months post-discharge. Factors associated with loss to follow-up were identified using a subsample of the data covering the period 2010-2013. RESULTS: Over the study period, the proportion of loss to follow-up was 21.5% (448/2080) and varied across repair hospitals and over time with an increase from 2% in 2009 to 52% in 2013. After adjusting for other variables in a multivariate logistic regression model, women who underwent surgery at Labe hospital and at Kissidougou hospital were more likely to be lost to follow-up than women operated at Jean Paul II hospital (OR: 50.6; 95% CI: 24.9-102.8) and (OR: 11.5; 95% CI: 6.1-22.0), respectively. Women with their fistula closed at hospital discharge (OR: 3.2; 95% CI: 2.1-4.8) and women admitted for repair in years 2011-2013 showed higher loss to follow-up as compared to 2010. Finally, loss to follow-up increased by 2‰ for each additional kilometre of distance a client lived from the repair hospital (OR: 1.002; 95% CI: 1.001-1.003). CONCLUSION: Reimbursement of transport was the likely reason for change over time of LTFU. Reducing geographical barriers to care for women with fistula could sustain fistula care positive outcomes.

Status of emergency obstetric care in four districts of Punjab, Pakistan - results of a baseline assessment.

OBJECTIVE: To assess the availability and quality of Emergency Obstetric and Newborn Care in four districts of Punjab. METHODS: The cross-sectional descriptive study was conducted in Attock, Gujranwala, Rahim Yar Khan and Khanewal districts of Pakistan's Punjab province. Data was collected in July 2012 from all District Headquarter Hospitals, Tehsil Headquarter Hospitals and selective Rural Health Centres (RHCs) using a pre-formatted questionnaire to assess availability of signal functions of Emergency Obstetric and Newborn Care, including staffing and equipment, number of births and women with complications, maternal case fatality rate and stillbirth rate. SPSS 20 was used for statistical analysis. RESULTS: In total, 32 health care facilities were surveyed: 14(43.75%) providing basic care and, 18(56.25) providing comprehensive obstetric care. All required signal functions were available at 4(22%) in the latter category, and 3(21%) facilities in the former category. Met need for Emergency Obstetric and Newborn Care was 17.8%. Besides, there were 26 maternal deaths among the 1,482 women with recognised obstetric complications, indicating an overall case fatality rate for all districts of 1.75%. CONCLUSIONS: Continued efforts are needed to improve the availability and quality of Emergency Obstetric and Newborn Care through targeted skill-based training and provision of adequate drugs and equipment.

Practical aspects of setting up obstetric skills laboratories--a literature review and proposed model.

OBJECTIVE: the use of simulation training in obstetrics is an important strategy to improve health-care providers׳ competence to manage obstetric cases. As an increasing number of international programmes focus on simulation training, more information is needed about the practical aspects of planning for and organising skills laboratories. METHODS: systematic review of peer reviewed literature published between January 2000 and June 2014. Thematic summary of 31 papers meeting inclusion criteria. FINDINGS: skills laboratories need to reflect the clinical working environment and are ideally located at or near a health-care facility. A mix of low and high fidelity manikins combined with patient actors is recommended to be used with clear instructions, scenario setting and short lectures including audio-visual teaching aids. Motivated trainers are vital and a focus on 'team training' in smaller groups is beneficial. Practical information needed to set up and run a skills laboratory is provided with a proposed outline of a skills laboratory for obstetric simulation training. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: obstetric skills laboratories can play a substantial role in increasing competency and confidence of staff via 'skills and drills' type training. When considering setting up skills laboratories, this can be simply done using low fidelity manikins in the first instance with training facilitated by motivated trainers using realistic clinical scenarios. Overall, the review findings highlight the need for better documentation of factors that promote and/or are barriers to the effective use of skills laboratories. SYNOPSIS: 31 papers detailing the planning and organisation of skills laboratories were reviewed in order to assess the factors necessary for their effectiveness and the vital role they play in increasing staff competencies. Setting up obstetric skills laboratories is worthwhile but requires in-depth planning.