Measuring maternal mortality: a systematic review of methods used to obtain estimates of the maternal mortality ratio (MMR) in low- and middle-income countries.

Background: The new global target for maternal mortality ratio (MMR) is a ratio below 70 maternal deaths per 100 000 live births by 2030. We undertook a systematic review of methods used to measure MMR in low- and middle-income countries. Sources of data: Systematic review of the literature; 59 studies included. Areas of agreement: Civil registration (5 studies), census (5) and surveys (16), Reproductive Age Mortality Studies (RAMOS) (4) and the sisterhood methods (11) have been used to measure MMR in a variety of settings. Areas of controversy: Middle-income countries have used civil registration data for estimating MMR but it has been a challenge to obtain reliable data from low-income countries with many only using health facility data (18 studies). Growing points and areas for further research: Based on the strengths and feasibility of application, RAMOS may provide reliable and contemporaneous estimates of MMR while civil registration systems are being introduced. It will be important to build capacity for this and ensure implementation research to understand what works where and how.

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.

Knowledge and Skills of Healthcare Providers in Sub-Saharan Africa and Asia before and after Competency-Based Training in Emergency Obstetric and Early Newborn Care.

BACKGROUND: Healthcare provider training in Emergency Obstetric and Newborn Care (EmOC&NC) is a component of 65% of intervention programs aimed at reducing maternal and newborn mortality and morbidity. It is important to evaluate the effectiveness of this. METHODS: We evaluated knowledge and skills among 5,939 healthcare providers before and after 3-5 days 'skills and drills' training in emergency obstetric and newborn care (EmOC&NC) conducted in 7 sub-Saharan Africa countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Zimbabwe) and 2 Asian countries (Bangladesh, Pakistan). Standardised assessments using multiple choice questions and objective structured clinical examination (OSCE) were used to measure change in knowledge and skills and the Improvement Ratio (IR) by cadre and by country. Linear regression was performed to identify variables associated with pre-training score and IR. RESULTS: 99.7% of healthcare providers improved their overall score with a median (IQR) increase of 10.0% (5.0% - 15.0%) for knowledge and 28.8% (23.1% - 35.1%) for skill. There were significant improvements in knowledge and skills for each cadre of healthcare provider and for each country (p<0.05). The mean IR was 56% for doctors, 50% for mid-level staff and nurse-midwives and 38% for nursing-aides. A teaching job, previous in-service training, and higher percentage of work-time spent providing maternity care were each associated with a higher pre-training score. Those with more than 11 years of experience in obstetrics had the lowest scores prior to training, with mean IRs 1.4% lower than for those with no more than 2 years of experience. The largest IR was for recognition and management of obstetric haemorrhage (49-70%) and the smallest for recognition and management of obstructed labour and use of the partograph (6-15%). CONCLUSIONS: Short in-service EmOC&NC training was associated with improved knowledge and skills for all cadres of healthcare providers working in maternity wards in both sub-Saharan Africa and Asia. Additional support and training is needed for use of the partograph as a tool to monitor progress in labour. Further research is needed to assess if this is translated into improved service delivery.