Resilience to maintain quality of intrapartum care in war torn Yemen: a retrospective pre-post study evaluating effects of changing birth volumes in a congested frontline hospital

Abstract

Background Fragile and conflict-affected states contribute with more than 60% of the global burden of maternal mortality. There is an alarming need for research exploring maternal health service access and quality and adaptive responses during armed conflict. Taiz Houbane Maternal and Child Health Hospital in Yemen was established during the war as such adaptive response. However, as number of births vastly exceeded the facility’s pre-dimensioned capacity, a policy was implemented to restrict admissions. We here assess the restriction’s effects on the quality of intrapartum care and birth outcomes. Methods A retrospective before and after study was conducted of all women giving birth in a high-volume month pre-restriction (August 2017; n = 1034) and a low-volume month post-restriction (November 2017; n = 436). Birth outcomes were assessed for all births (mode of birth, stillbirths, intra-facility neonatal deaths, and Apgar score < 7). Quality of intrapartum care was assessed by a criterion-based audit of all caesarean sections (n = 108 and n = 82) and of 250 randomly selected vaginal births in each month. Results Background characteristics of women were comparable between the months. Rates of labour inductions and caesarean sections increased significantly in the low-volume month (14% vs. 22% (relative risk (RR) 0.62, 95% confidence interval (CI) 0.45-0.87) and 11% vs. 19% (RR 0.55, 95% CI 0.42-0.71)). No other care or birth outcome indicators were significantly different. Structural and human resources remained constant throughout, despite differences in patient volume. Conclusions Assumptions regarding quality of care in periods of high demand may be misguiding - resilience to maintain quality of care was strong. We recommend health actors to closely monitor changes in quality of care when implementing resource changes; to enable safe care during birth for as many women as possible.

Labor augmentation with oxytocin in low- and lower-middle-income countries: a systematic review and meta-analysis

“…To assess the rate of oxytocin for labor augmentation, 41 studies were eligible, including either all women in labor, 16 , 22 , 33 , 34 , 40 , 41 , 42 , 43 vaginal births only, 9 , 31 , 37 , 39 , 44 , 45 , 46 women with uncomplicated singleton cephalic pregnancies at term, 11 , 17 , 18 , 19 , 32 , 35 , 38 , 47 , 48 , 49 , 50 , 51 or other criteria. 36 , 52 , 53 , 54 Data collection methods were by nonvalidated medical records, 11 , 16 , 17 , 19 , 28 , 32 , 33 , 40 , 41 , 42 , 43 , 45 , 46 , 51 , 54 clinical observations, 9 , 18 , 28 , 31 , 34 , 35 , 36 , 37 , 38 , 48 , 49 , 50 , 53 questionnaires, ...…”

Estimating stillbirth and neonatal mortality rate among Rohingya refugees in Bangladesh, September 2017 to December 2018: a prospective surveillance

“…There are few comparison points for stillbirth rates in refugee settings, however, our results are comparable to the estimated stillbirth rate (14.0 per 1000 live births) of Myanmar where Rohingya refugees migrated from for 2019 10. Previous studies in conflict-settings have found that several factors influence quality of care provided during labour and childbirth, including structural factors, such as availability of the necessary equipment, drugs and supplies at the health facility, skilled healthcare workers, coordination between implementing agencies, surveillance systems and use of data for programmatic action, referral systems and patient volume 15 16…”

“…Indeed, the lack of data on neonatal mortality and stillbirths are not unique for the Rohingya crisis. Few studies have reported neonatal mortality12–14 and even fewer studies report stillbirths in the acute phase of humanitarian crises 15 16. This is due, in large part, to complex methodological challenges in the acute phase of a humanitarian crisis.…”

Research progress of health care in Yemeni children during the war: review

“…Despite the significant changes in the population, the data collection has become extremely difficult, since the war divided the country into rebel-controlled and government-controlled regions (Oakford, 2019). With this challenge, there is an urgent need for research into the availability and quality of child and maternal health services, as well as adaptive responses during armed conflict (Obel, Martin et al, 2021).…”