BackgroundEfforts to improve maternal health are increasingly focused on improving the quality of care provided to women at health facilities, including the promotion of respectful care and eliminating mistreatment of women during childbirth. A WHO-led multi-country research project aims to develop and validate two tools (labor observation and community survey) to measure how women are treated during facility-based childbirth. This paper describes the development process for these measurement tools, and how they were implemented in a multi-country study (Ghana, Guinea, Myanmar and Nigeria).MethodsAn iterative mixed-methods approach was used to develop two measurement tools. Methodological development was conducted in four steps: (1) initial tool development; (2) validity testing, item adjustment and piloting of paper-based tools; (3) conversion to digital, tablet-based tools; and (4) data collection and analysis. These steps included systematic reviews, primary qualitative research, mapping of existing tools, item consolidation, peer review by key stakeholders and piloting.ResultsThe development, structure, administration format, and implementation of the labor observation and community survey tools are described. For the labor observations, a total of 2016 women participated: 408 in Nigeria, 682 in Guinea, and 926 in Ghana. For the community survey, a total of 2672 women participated: 561 in Nigeria, 644 in Guinea, 836 in Ghana, and 631 in Myanmar. Of the 2016 women who participated in the labor observations, 1536 women (76.2%) also participated in the community survey and have linked data: 779 in Ghana, 425 in Guinea, and 332 in Nigeria.ConclusionsAn important step to improve the quality of maternity care is to understand the magnitude and burden of mistreatment across contexts. Researchers and healthcare providers in maternal health are encouraged to use and implement these tools, to inform the development of more women-centered, respectful maternity healthcare services. By measuring the prevalence of mistreatment of women during childbirth, we will be able to design and implement programs and policies to transform maternity services.Electronic supplementary materialThe online version of this article (10.1186/s12874-018-0603-x) contains supplementary material, which is available to authorized users.

Use of cesarean delivery is limited in the African health facilities surveyed. Emergency cesareans, when performed, are often too late to reduce perinatal deaths.

Objective: To explore what "quality of care" means to childbearing women in Nigeria and Uganda, as a means of ensuring that women's voices and opinions are prioritized when developing interventions to improve quality in maternity care provision. Methods:Qualitative methods, with a purposive sample of women in Nigeria and Uganda. Participants were asked to define quality of care and to provide examples of when it was and was not provided. Thematic analysis was used to synthesize findings based on an a priori framework (the WHO quality of care framework).Results: 132 in-depth interviews and 21 focus group discussions are included.Participants spontaneously discussed each of the WHO framework domains of quality of care. Data were richest across the domains of effective communication, respect and dignity, emotional support, competent and motivated human resources, and essential physical resources. Women believed that good quality of care ensured optimal psychological and physiological outcomes for the woman and her baby. Positive interpersonal relationships between women and health providers were important. These included supportive care, building rapport, and using positive and clear language. Conclusion:To provide good quality of care, maternity services should consider and act on the expectations and experiences of women and their families.

I n areas without adequate medical facilities and resources, cesarean delivery (CD) can increase maternal and newborn risks and raise medical costs. It is also a marker for the availability and use of obstetric services in resource-poor countries. This survey studied the mode of delivery and maternal and perinatal outcomes in African health facilities and the association of institutional CD rates with maternal and perinatal morbidity and mortality. Data from 7 of 46 African countries who are surveyed by the World Health Organization for maternal and perinatal health were randomly selected for inclusion. The data from each country were divided and recombined into 21 geographic units, covering the capital city of each country, and 2 randomly selected provinces in every participating country (Algeria, Angola, Democratic Republic of Cong, Niger, Nigeria, Kenya, and Uganda). From 699 health facilities in the geographic areas, 133 were randomly selected (2 facilities declined to participate). Among these 131 facilities, 83,439 deliveries were recorded during the study period. Maternal data included risk indicators, the mode of delivery, and maternal and newborn outcomes until discharge or during hospital stay up until 7 days postpartum. Institutional outcomes included adequacy of laboratory tests, amount of anesthesia resources, measures of intrapartum care including emergency obstetric care, and the amount of human resources. A health facility classification score (HFCS) was determined based on basic services, general medical services, availability of screening tests, emergency obstetric care, intrapartum care, and human resources. Each domain was scored as basic, comprehensive, or advanced, and the sum of the scores comprised the HFCS.Most births (81.7%) occurred in governmental facilities. Thirty facilities overall had low HFCS; 54 and 47 facilities had medium and high scores, respectively, and 1% charged fees for delivery. The median CD rate was 8.8% but such deliveries were performed in only 95 (72.5%) of the facilities. Among facilities doing CDs, the median rate for CD was 13.4% of deliveries (range, 2.3%-27.3%). Facilities with higher percentages of women with previous CD, preeclampsia, induced labor, referrals, and higher HFCS had higher CD rates. Midwives did 75% of the normal deliveries and specialist and trainee obstetricians, general physicians, and nonphysicians performed 60%, 33%, and 6% of CDs, respectively. Nearly 50% of operative vaginal deliveries (3% of all deliveries) were performed by midwives, nurses, or other paramedical personnel. CDs were performed for cephalopelvic disproportion, dystocia, or failure to progress in 30.9% of patients, for fetal indications in 25%, for previous CD in 21.5%, and malpresentation in 13% of patients. Socio-demographic characteristics, past reproductive history, variables in the current pregnancy and during childbirth, and facility characteristics accounted for 64%, 41%, 35%, and 44% of the variation in CD rates among the institutions, respectively. The overall mate...

UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

(Abstracted from New Engl J Med 2018;379:743–752) Postpartum hemorrhage is the most common cause of maternal death. Oxytocin is the standard therapy for the prevention of postpartum hemorrhage, but it requires cold storage, which is not available in many countries, and has unsatisfactory real-world efficacy as a result of heat sensitivity and quality issues such as insufficient active ingredient or impurities.

BackgroundPeripartum hysterectomy can cause significant morbidity and mortality. Most studies of peripartum hysterectomy are from high income countries. This cohort study examined risk factors for peripartum hysterectomy using data from Africa, Asia, Europe and the Americas.MethodsWe used data from the World Maternal Antifibrinolytic (WOMAN) trial carried out in 193 hospitals in 21 countries. Peripartum hysterectomy was defined as hysterectomy within 6 weeks of delivery as a complication of postpartum haemorrhage. Univariable and multivariable random effects logistic regression models were used to analyse risk factors. A hierarchical conceptual framework guided our multivariable analysis.ResultsFive percent of women had a hysterectomy (1020/20,017). Haemorrhage from placenta praevia/accreta carried a higher risk of hysterectomy (17%) than surgical trauma/tears (5%) and uterine atony (3%). The adjusted odds ratio (AOR) for hysterectomy in women with placenta praevia/accreta was 3.2 (95% CI: 2.7–3.8), compared to uterine atony. The risk of hysterectomy increased with maternal age. Caesarean section was associated with fourfold higher odds of hysterectomy than vaginal delivery (AOR 4.3, 95% CI: 3.6–5.0). Mothers in Asia had a higher hysterectomy incidence (7%) than mothers in Africa (5%) (AOR: 1.2, 95% CI: 0.9–1.7).ConclusionsPlacenta praevia/accreta is associated with a higher risk of peripartum hysterectomy. Other risk factors for hysterectomy are advanced maternal age, caesarean section and giving birth in Asia.

Analysis 1.9. Comparison 1 Biophysical profile versus conventional fetal monitoring (CTG), Outcome 9 Caesarean section........ Analysis 1.10. Comparison 1 Biophysical profile versus conventional fetal monitoring (CTG), Outcome 10 Caesarean section for fetal distress.