Monitoring obstetric services: putting the ‘UN Guidelines’ into practice in Malawi: 3 years on

Abstract

The maternal mortality ratio is difficult to use for monitoring short-term progress in safe motherhood programs. UNICEF/WHO/UNFPA have proposed alternative process indicators monitoring the availability, utilization and quality of obstetric services. There is little experience in the large-scale use of these indicators as part of routine health information systems in developing countries. The Malawi Safe Motherhood Project, which covers a population of over 5 million, was one of the first large projects to implement the new process indicators. At the end of 2000 data were available from the new monitoring system for 3 consecutive years. In 1998, availability of comprehensive emergency obstetric care was adequate but availability of basic emergency obstetric care was very poor. Although institutional delivery rates were over 30%, the met need for obstetric care was only 19.8% and the cesarean section rate was only 1.6%. The mean case fatality rate in District hospitals was nearly 5%. By the end of 2000, improvements in availability, utilization and quality of obstetric care were observed. Participation in developing the monitoring system had also created a strong sense of ownership and interest in analyzing and using the data. Several issues have emerged from routine use of the process indicators. In particular, it has been difficult to be certain that obstetric complications have been recorded correctly. The results confirm that a focus on improving emergency obstetric care in Malawi was justified and that process indicators for obstetric care can be successfully introduced in developing countries. The monitoring system has provided data that are of immediate relevance to service providers, managers, and policy makers and provide many lessons useful for similar programs in other settings.

Millennium development goal 5: a review of maternal mortality at the Kenyatta National Hospital, Nairobi

“…Locally and internationally, a three pronged evidence based approach has been shown to work in reducing maternal mortality, and these are family planning, delivery with skilled attendants and emergency basic and comprehensive obstetric care (15,16).…”

Stillbirths

“…[63][64][65][66] These stillbirths occur in conjunction with prolonged/obstructed labor; antepartum hemorrhage, including placental abruption and previa; preeclampsia/eclampsia; fetal growth restriction; postdates; fetal distress; cord accidents; and abnormal presentations and multiple births. Most of these conditions do not cause stillbirth in settings with high-quality obstetric care.…”

“…Qualified staffing and availability of cesarean section must be available 24 hours a day and 7 days a week, a situation not often seen in many LMIC hospitals. 66 Both the 2011 and 2015 Lancet "Stillbirth Series" estimated various interventions and their impact on stillbirths. Above all, appropriate hospital-based obstetric care during labor and delivery stood out as the most effective way to prevent stillbirths in LMICs.…”

Caesarean section in Malawi: prospective study of early maternal and perinatal mortality

“…It has since risen to an estimated 1120 per 100 0009 compared with 10 per 100 000 in developed countries. Caesarean section has a much higher mortality for mother and baby in Africa than in industrialised countries,10 and improvements may be possible.…”