Gravid uterine torsion less than 45 degrees is a common phenomenon of the third trimester. Torsion greater than 45 degrees represents a rare, pathologic, and obstetric emergency. The rotation of the uterus on a longitudinal plane can result in vascular compromise, and it has potential for catastrophic maternal-fetal complications. We report the case of a 22-year-old G3P1011, third pregnancy with history of one full-term live newborn, one spontaneous abortion, and presented at 38 weeks gestation with complaints of abdominal pressure and recurrent transverse fetal presentation. She underwent an external cephalic version (ECV), which resulted in fetal distress necessitating an emergency cesarean section. After successful delivery of the live newborn, an inspection of the uterus identified a uterine torsion of 180 degrees with delivery through a posterior hysterotomy incision. She had no postoperative complications and carried a subsequent pregnancy to term that was delivered via repeat cesarean section five years later. Gravid uterine torsion should be included in the differential diagnosis for patients presenting with abdominal pain and fetal intolerance to labor. A higher suspicion should be held for patients with a known history of uterine abnormalities or those having undergone an ECV. Our case also highlights a safe repeat cesarean section after this rare complication and brief narrative review of existing literature on this rare obstetrical emergency.

BACKGROUND: In 2016, the WHO regional office for Europe prepared a manual for conducting routine facility based individual near miss case review cycle. This study evaluates the effectiveness of the individual near miss case review (NMCR) cycle in improving quality of emergency obstetric care and maternal outcome in Keren hospital.
METHODS: An interrupted time series design was used to achieve the objectives of this study. Monthly data on women with potentially life-threatening conditions (PLTCs) admitted between April 2018 and October 2022 (i.e. 33 months pre-implementation and 22 months post-implementation) were collected from medical records. Segmented regression analysis was used to assess the intervention\'s effect on three process and outcome measures, namely, SMO, delayed care, and substandard care. The intervention was expected a priori to show immediate improvements without time-lag followed by gradual increment in slope. Segmented regression analyses were performed using the \"itsa\' command in STATA.
RESULTS: During the entire study period, 4365 women with potentially life threatening conditions were identified. There was a significant reduction in the post-implementation period in the proportion of mothers with PLTC who experienced SMO (- 8.86; p <  0.001), delayed care (- 8.76; p <  0.001) and substandard care (- 5.58; p <  0.001) compared to pre-implementation period. Results from the segmented regression analysis revealed that the percentage of women with SMO showed a significant 4.75% (95% CI: - 6.95 to - 2.54, p <  0.001) reduction in level followed by 0.28 percentage points monthly (95% CI: - 0.37 to - 0.14, p <  0.001) drop in trend. Similarly, a significant drop of 3.50% (95% CI: - 4.74 to - 2.26, p <  0.001) in the level of substandard care along with a significant decrease of 0.21 percentage points (95% CI: - 0.28 to - 0.14, p < 0.001) in the slope of the regression line was observed. The proportion of women who received delayed care also showed a significant 7% (95% CI: - 9.28 to - 4.68, p < 0.001) reduction in post-implementation level without significant change in slope.
CONCLUSIONS: Our findings suggest that the WHO individual NMCR cycle was associated with substantial improvements in quality of emergency obstetric care and maternal outcome. The intervention also bears a great potential for scaling-up following the guidance provided in the WHO NMCR manual.

BACKGROUND: Over 80,000 pregnant women died in Nigeria due to pregnancy-related complications in 2020. Evidence shows that if appropriately conducted, caesarean section (CS) reduces the odds of maternal death. In 2015, the World Health Organization (WHO), in a statement, proposed an optimal national prevalence of CS and recommended the use of Robson classification for classifying and determining intra-facility CS rates. We conducted this systematic review and meta-analysis to synthesise evidence on prevalence, indications, and complications of intra-facility CS in Nigeria.
METHODS: Four databases (African Journals Online, Directory of Open Access Journals, EBSCOhost, and PubMed) were systematically searched for relevant articles published from 2000 to 2022. Articles were screened following the PRISMA guidelines, and those meeting the study\'s inclusion criteria were retained for review. Quality assessment of included studies was conducted using a modified Joanna Briggs Institute\'s Critical Appraisal Checklist. Narrative synthesis of CS prevalence, indications, and complications as well as a meta-analysis of CS prevalence using R were conducted.
RESULTS: We retrieved 45 articles, with most (33 (64.4%)) being assessed as high quality. The overall prevalence of CS in facilities across Nigeria was 17.6%. We identified a higher prevalence of emergency CS (75.9%) compared to elective CS (24.3%). We also identified a significantly higher CS prevalence in facilities in the south (25.5%) compared to the north (10.6%). Furthermore, we observed a 10.7% increase in intra-facility CS prevalence following the implementation of the WHO statement. However, none of the studies adopted the Robson classification of CS to determine intra-facility CS rates. In addition, neither hierarchy of care (tertiary or secondary) nor type of facility (public or private) significantly influenced intra-facility CS prevalence. The commonest indications for a CS were previous scar/CS (3.5-33.5%) and pregnancy-related hypertensive disorders (5.5-30.0%), while anaemia (6.4-57.1%) was the most reported complication.
CONCLUSIONS: There are disparities in the prevalence, indications, and complications of CS in facilities across the geopolitical zones of Nigeria, suggestive of concurrent overuse and underuse. There is a need for comprehensive solutions to optimise CS provision tailor-made for zones in Nigeria. Furthermore, future research needs to adopt current guidelines to improve comparison of CS rates.

The objective of the study was to review the evidence on interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub-Saharan Africa (SSA).
A systematic search of PubMed, Embase, Cochrane Register and CINAHL Plus was conducted to identify studies on obstetric emergency referral in SSA. Studies were included based on pre-defined eligibility criteria. Details of reported referral interventions were extracted and categorised. The Joanna Biggs Institute Critical Appraisal checklists were used for quality assessment of included studies. A formal narrative synthesis approach was used to summarise findings guided by the WHO\'s referral system flow.
A total of 14 studies were included, with seven deemed high quality. Overall, 7 studies reported referral decision-making interventions including training programmes for health facility and community health workers, use of a triage checklist and focused obstetric ultrasound, which resulted in improved knowledge and practice of recognising danger signs for referral. 9 studies reported on referral communication using mobile phones and referral letters/notes, resulting in increased communication between facilities despite telecommunication network failures. Referral decision making and communication interventions achieved a perceived reduction in maternal mortality. 2 studies focused on referral feedback, which improved collaboration between health facilities.
There is limited evidence on how well referral interventions work in sub-Saharan Africa, and limited consensus regarding the framework underpinning the expected change. This review has led to the proposition of a logic model that can serve as the base for future evaluations which robustly expose the (in)efficiency of referral interventions.

Providing quality emergency obstetric care (EmOC) reduces the risk of maternal and newborn mortality and morbidity. There is evidence that over 50% of maternal health programmes that result in improving access to EmOC and reduce maternal mortality have an EmOC training component. The objective was to review the evidence for the effectiveness of training in EmOC. Eleven databases and websites were searched for publications describing EmOC training evaluations between 1997 and 2017. Effectiveness was assessed at four levels: (1) participant reaction, (2) knowledge and skills, (3) change in behaviour and clinical practice and (4) availability of EmOC and health outcomes. Weighted means for change in knowledge and skills obtained, narrative synthesis of results for other levels. One hundred and one studies including before-after studies (n = 44) and randomized controlled trials (RCTs) (n = 15). Level 1 and/or 2 was assessed in 68 studies; Level 3 in 51, Level 4 in 21 studies. Only three studies assessed effectiveness at all four levels. Weighted mean scores pre-training, and change after training were 67.0% and 10.6% for knowledge (7750 participants) and 53.1% and 29.8% for skills (6054 participants; 13 studies). There is strong evidence for improved clinical practice (adherence to protocols, resuscitation technique, communication and team work) and improved neonatal outcomes (reduced trauma after shoulder dystocia, reduced number of babies with hypothermia and hypoxia). Evidence for a reduction in the number of cases of post-partum haemorrhage, case fatality rates, stillbirths and institutional maternal mortality is less strong. Short competency-based training in EmOC results in significant improvements in healthcare provider knowledge/skills and change in clinical practice. There is emerging evidence that this results in improved health outcomes.

Nearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women\'s access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa.
Articles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings.
The search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff.
A number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness.
PROSPERO CRD42017074102.

Nearly 15% of all pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labor, and complications of abortion. Between 1990 and 2015, an estimated 10.7 million women died due to obstetric complications. Almost all of these deaths (99%) happened in developing countries, and 66% of maternal deaths were attributed to sub-Saharan Africa. The majority of cases of maternal mortalities can be prevented through provision of evidence-based potentially life-saving signal functions of emergency obstetric care. However, different factors can hinder women\'s ability to access and use emergency obstetric services in sub-Saharan Africa. Therefore, the aim of this review is to synthesize current evidence on barriers to accessing and utilizing emergency obstetric care in sub-Saharan African. Decision-makers and policy formulators will use evidence generated from this review in improving maternal healthcare particularly the emergency obstetric care.
Electronic databases including MEDLINE, CINAHL, Embase, and Maternity and Infant Care will be searched for studies using predefined search terms. Articles published in English language between 2010 and 2017 with quantitative and qualitative design will be included. The identified papers will be assessed for meeting eligibility criteria. First, the articles will be screened by examining their titles and abstracts. Then, two reviewers will review the full text of the selected articles independently. Two reviewers using a standard data extraction format will undertake data extraction from the retained studies. The quality of the included papers will be assessed using the mixed methods appraisal tool. Results from the eligible studies will be qualitatively synthesized using the narrative synthesis approach and reported using the three delays model. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist will be employed to present the findings.
This systematic review will present a detailed synthesis of the evidence for barriers to access and utilization of emergency obstetric care in sub-Saharan Africa over the last 7 years. This systematic review is expected to provide clear information that can help in designing maternal health policy and interventions particularly in emergency obstetric care in sub-Saharan Africa where maternal mortality remains high.
PROSPERO CRD42017074102 .

Maternal morbidity and mortality is most prevalent in resource-poor settings such as sub-Saharan Africa and southern Asia. In sub-Saharan Africa, Ghana is one of the countries still facing particular challenges in reducing its maternal morbidity and mortality. Access to emergency obstetric care (EmOC) interventions has been identified as a means of improving maternal health outcomes. Assessing the range of interventions provided in health facilities is, therefore, important in determining capacity to treat obstetric emergencies. The aim of this study was to examine the availability of emergency obstetric care interventions in the Upper East Region of Ghana.
A cross-sectional survey of 120 health facilities was undertaken. Status of emergency obstetric care was assessed through an interviewer administered questionnaire to directors/in-charge officers of maternity care units in selected facilities. Data were analysed using descriptive statistics.
Eighty per cent of health facilities did not meet the criteria for provision of emergency obstetric care. Comparatively, private health facilities generally provided EmOC interventions less frequently than public health facilities. Other challenges identified include inadequate skill mix of maternity health personnel, poor referral processes, a lack of reliable communication systems and poor emergency transport systems.
Multiple factors combine to limit women\'s access to a range of essential maternal health services. The availability of EmOC interventions was found to be low across the region; however, EmOC facilities could be increased by nearly one-third through modest investments in some existing facilities. Also, the key challenges identified in this study can be improved by enhancing pre-existing health system structures such as Community-based Health Planning and Services (CHPS), training more midwifery personnel, strengthening in-service training and implementation of referral audits as part of health service monitoring. Gaps in availability of EmOC interventions, skilled personnel and referral processes must be tackled in order to improve obstetric outcomes.

BACKGROUND: Training healthcare providers in Emergency Obstetric Care (EmOC) has been shown to be effective in improving their capacity to provide this critical care package for mothers and babies. However, little is known about the costs and cost-effectiveness of such training. Understanding costs and cost-effectiveness is essential in guaranteeing value-for-money in healthcare spending. This study systematically reviewed the available literature on cost and cost-effectiveness of EmOC trainings.
METHODS: Peer-reviewed and grey literature was searched for relevant papers published after 1990. Studies were included if they described an economic evaluation of EmOC training and the training cost data were available. Two reviewers independently searched, screened, and selected studies that met the inclusion criteria, with disagreements resolved by a third reviewer. Quality of studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. For comparability, all costs in local currency were converted to International dollar (I$) equivalents using purchasing power parity conversion factors. The cost per training per participant was calculated. Narrative synthesis was used to summarise the available evidence on cost effectiveness.
RESULTS: Fourteen studies (five full and nine partial economic evaluations) met the inclusion criteria. All five and two of the nine partial economic evaluations were of high quality. The majority of studies (13/14) were from low- and middle-income countries. Training equipment, per diems and resource person allowance were the most expensive components. Cost of training per person per day ranged from I$33 to I$90 when accommodation was required and from I$5 to I$21 when training was facility-based. Cost-effectiveness of training was assessed in 5 studies with differing measures of effectiveness (knowledge, skills, procedure cost and lives saved) making comparison difficult.
CONCLUSIONS: Economic evaluations of EmOC training are limited. There is a need to scale-up and standardise processes that capture both cost and effectiveness of training and to agree on suitable economic evaluation models that allow for comparability across settings.
BACKGROUND: PROSPERO_CRD42016041911 .

Many interventions have been implemented to improve maternal health outcomes in sub-Saharan Africa (SSA). Currently, however, systematic information on the effectiveness of these interventions remains scarce. We conducted a systematic review of published evidence on non-drug interventions that reported effectiveness in improving outcomes and quality of care in maternal health in SSA.
African Journals Online, Bioline, MEDLINE, Ovid, Science Direct, and Scopus databases were searched for studies published in English between 2000 and 2015 and reporting on the effectiveness of interventions to improve quality and outcomes of maternal health care in SSA. Articles focusing on interventions that involved drug treatments, medications, or therapies were excluded. We present a narrative synthesis of the reported impact of these interventions on maternal morbidity and mortality outcomes as well as on other dimensions of the quality of maternal health care (as defined by the Institute of Medicine 2001 to comprise safety, effectiveness, efficiency, timeliness, patient centeredness, and equitability).
Seventy-three studies were included in this review. Non-drug interventions that directly or indirectly improved quality of maternal health and morbidity and mortality outcomes in SSA assumed a variety of forms including mobile and electronic health, financial incentives on the demand and supply side, facility-based clinical audits and maternal death reviews, health systems strengthening interventions, community mobilization and/or peer-based programs, home-based visits, counseling and health educational and promotional programs conducted by health care providers, transportation and/or communication and referrals for emergency obstetric care, prevention of mother-to-child transmission of HIV, and task shifting interventions. There was a preponderance of single facility and community-based studies whose effectiveness was difficult to assess.
Many non-drug interventions have been implemented to improve maternal health care in SSA. These interventions have largely been health facility and/or community based. While the evidence on the effectiveness of interventions to improve maternal health is varied, study findings underscore the importance of implementing comprehensive interventions that strengthen different components of the health care systems, both in the community and at the health facilities, coupled with a supportive policy environment.
PROSPERO CRD42015023750.