UNASSIGNED: To reduce maternal mortality by 2030, Benin needs to implement strategies for improving access to high quality emergency obstetric and neonatal care (EmONC). This study applies an expert-based approach using sub-national travel specificities to identify and prioritize a network of EmONC maternities that maximizes both population coverage and functionality.
UNASSIGNED: We conducted a series of workshops involving international, national, and department experts in maternal health to prioritize a set of EmONC facilities that meet international standards. Geographical accessibility modeling was used together with EmONC availability to inform the process. For women in need of EmONC, experts provided insights into travel characteristics (i.e., modes and speeds of travel) specific to each department, enabling more realistic travel times estimates modelled with the AccessMod software.
UNASSIGNED: The prioritization approach resulted in the selection of 109 EmONC maternities from an initial group of 125 designated maternities. The national coverage of the population living within an hour\'s drive of the nearest EmONC maternity increased slightly from 92.6% to 94.1% after prioritization. This increase in coverage was achieved by selecting maternities with sufficient obstetrical activities to be upgraded to EmONC maternities in the Plateau and Atlantique departments.
UNASSIGNED: The prioritization approach enabled Benin to achieve the minimum EmONC availability, while ensuring very good geographical accessibility to the prioritized network. Limited human and financial resources can now be targetted towards a smaller number of EmONC facilities to make them fully functioning in the medium-term. By implementing this strategy, Benin aims to reduce maternal mortality rates and deliver effective, high-quality obstetric and neonatal care, especially during emergencies.

UNASSIGNED: UP has the 2nd highest MMR which is 197 compared with national average of 113 (RGI-SRS-2016-2018).Although institutional deliveries in India has been increased from 78.9% (NFHS-4) to 89% (NFHS-5) [ UP from 67.8% to 83.4%] but still we are far away from SDG -3 target. It reflects that there may be increase in crude coverage but not in effective coverage.
UNASSIGNED: It is a cross sectional study conducted in May - June 2017. Out of 8 blocks of rural Varanasi, 4 blocks were selected randomly. Best functioning facility for EmOC services in each selected block were assessed using Facility Gap Assessment Schedule of IPHS.
UNASSIGNED: None of the facility met the recommended standard for BEmOC .Tracking of drop out of ANC and PNC services, use of Partograph, treatment of abortion-related complications, were not found at all the 4 facility. Blood grouping and RH typing was also not functional at 2 of the 4 centers. Caesarean section and availability of blood bank were also lacking in CHC (FRU).
UNASSIGNED: If condition of best functioning facility in a block is not according to the recommendation then how can we expect to provide a good maternal health service to public.

Low rates of caesarean delivery (CD) (<10%) hinder access to a lifesaving procedure for the most vulnerable populations in low-resource settings, but there is a paucity of data regarding which factors contribute most to CD rates.
We aimed to determine caesarean delivery rates at Bihar\'s first referral units (FRUs) stratified by facility level (regional, sub-district, district). The secondary aim was to identify facility-level factors associated with caesarean delivery rates.
This cross-sectional study used open-source national datasets from government FRUs in Bihar, India, from April 2018-March 2019. Multivariate Poisson regression analysed association of infrastructure and workforce factors with CD rates.
Of 546,444 deliveries conducted at 149 FRUs, 16961 were CDs, yielding a state-wide FRU CD of 3.1%. There were 67 (45%) regional hospitals, 45 (30%) sub-district hospitals, and 37 (25%) district hospitals. Sixty-one percent of FRUs qualified as having intact infrastructure, 84% had a functioning operating room, but only 7% were LaQshya (Labour Room Quality Improvement Initiative) certified. Considering workforce, 58% had an obstetrician-gynaecologist (range 0-10), 39% had an anaesthetist (range 0-5), and 35% had a provider trained in Emergency Obstetric Care (EmOC) (range 0-4) through a task-sharing initiative. The majority of regional hospitals lack the essential workforce and infrastructure to perform CDs. Multivariate regression including all FRUs performing deliveries demonstrated that presence of a functioning operating room (IRR = 21.0, 95%CI 7.9-55.8, p < 0.001) and the number of obstetrician-gynaecologists (IRR = 1.3, 95%CI 1.1-1.4, p = 0.001) and EmOCs (IRR = 1.6, 95%CI 1.3-1.9, p < 0.001) were associated with facility-level CD rates.
Only 3.1% of the institutional childbirths in Bihar\'s FRUs were by CD. The presence of a functional operating room, obstetrician, and task-sharing provider (EmOC) was strongly associated with CD. These factors may represent initial investment priorities for scaling up CD rates in Bihar.

UNASSIGNED: Maternal mortality rate remains a challenge in many developing countries.
UNASSIGNED: This study explored experiences of Health Care Workers on Emergency Obstetrics Care (EMOC) in-service training and its effect on maternal mortality.
UNASSIGNED: Descriptive qualitative study design was conducted using in-depth interviews and focus group discussions. Participants were EMOC trained midwives and doctors purposively selected from the 2 referral hospitals in the country. Data were transcribed verbatim, coded, and analysed using Grounded Theory approach.
UNASSIGNED: Four themes emerged including training, EMOC implementation, maternal death factors and EMOC prioritisation. The duration of training was viewed inadequate but responsiveness to and confidence in managing obstetric emergencies improved post EMOC training. Staff shortage, HCWs non-adherence and negative attitude to EMOC guidelines; delays in instituting interventions, inadequate community involvement, minimal or no health talk to women and their partners and communities on sexual reproductive matters and non-prioritisation of EMOC by authorities were concerns raised.
UNASSIGNED: Strengthening health education at health facility levels, stakeholders\' involvement; and prioritising EMOC in-service training are necessary in reducing the national maternal mortality.

OBJECTIVE: Maternal brought in dead are the patient who dies in the need of adequate medical care. These deaths are often not analyzed sincerely as they are not institutional deaths. Our aim is to find out actual life threatening cause of delay leading to death.
METHODS: Patients brought dead to casualty were seen by the doctors on duty in Department of Obstetrics and Gynaecology,Gandhi Medical College, Bhopal round the clock. Cause of death was analyzed by verbal autopsy of attendants and referral letter from the institute. In this analytical study a complete evaluation of brought deaths from January 2011 to Decmeber 2014 was done.
RESULTS: A total of 64 brought in deaths were reported in this 4 year duration. Most common cause of death was postpartum hemorrhage (54.68 %) followed by hypertension (15.62 %) and the most common cause of delay was delay in getting adequate treatment (56.25 %).
CONCLUSIONS: The brought in dead are the indicator of the three delays in getting health care. Challenges appear to be enormous to be tackled. Timely management proves to be critical in preventing maternal death. Thus it appears that community education about pregnancy and its complications, EmOC training at FRU and strict adherence to referral protocol may help us to reduce the brought dead burden.

BACKGROUND: Bypassing available facilities for childbirth has important implications for maternal health service delivery and human resources within a health system. The results are the additional expenses imposed on the woman and her family, as well as the inefficient use of health system resources. Bypassing often indicates a lack of confidence in the care provided by the facility nearest to the mother, which implies a level of dysfunctionality that the health system needs to address. Over the past decade, India has experienced a steep rise in the proportion of facility births. The initiation of programs promoting facility births resulted in a rise from 39% in 2005 to 85% in 2014. There have been no reports on bypassing facilities for childbirth from India. In the context of steeply rising facility births, it is important to quantify the occurrence of and study the relative contributions of maternal characteristics and facility functionality to bypassing.
OBJECTIVE: 1) To determine the extent of bypassing health facilities for childbirth among rural mothers in three districts of Gujarat, India, 2) to identify associations between the functionality of an obstetric care (OC) facility and it being bypassed, and 3) to assess the relative contribution of maternal and facility characteristics to bypassing.
METHODS: A cross-sectional survey of 166 public and private OC facilities reporting ≥30 births in the 3 months before the survey was conducted in three purposively selected districts (Dahod, Sabarkantha, and Surendranagar) in the state of Gujarat, India. Besides information on each facility, data from 946 women giving birth at these facilities were also gathered. Data were analyzed using a multilevel mixed-effects logistic regression model.
RESULTS: Off all mothers, 37.7% bypassed their nearest facility for childbirth. After adjusting for maternal characteristics, for every one-unit increase in the facility\'s emergency obstetric care (EmOC) signal functions, the odds of bypassing a facility for childbirth decreased by 37% (adjusted odds ratio [AOR] 0.63, 95% confidence interval [CI]: 0.53-0.76).
CONCLUSIONS: This study shows that independent of maternal characteristics, in our setting, women will bypass obstetric facilities that are not adequately functional, and travel further to others that are more functional. It is important that the health system should focus on facility functionality, especially in the context of sharply rising hospital births.

India has experienced a steep rise in institutional childbirth. The relative contributions of public and private sector facilities to emergency obstetric care (EmOC) has not been studied in this setting. This paper aims to study in three districts of Gujarat state, India:(a) the availability of EmOC facilities in the public and private sectors; (b) the availability and distribution of human resources for birth attendance in the two sectors; and (c) to benchmark the above against 2005 World Health Report benchmarks (WHR2005).
A cross-sectional survey of obstetric care facilities reporting 30 or more births in the last three months was conducted (n = 159). Performance of EmOC signal functions and availability of human resources were assessed.
EmOC provision was dominated by private facilities (112/159) which were located mainly in district headquarters or small urban towns. The number of basic and comprehensive EmOC facilities was below WHR2005 benchmarks. A high number of private facilities performed C-sections but not all basic signal functions (72/159). Public facilities were the main EmOC providers in rural areas and 40/47 functioned at less than basic EmOC level. The rate of obstetricians per 1000 births was higher in the private sector.
The private sector is the dominant EmOC provider in the state. Given the highly skewed distribution of facilities and resources in the private sector, state led partnerships with the private sector so that all women in the state receive care is important alongside strengthening the public sector.

OBJECTIVE: To evaluate the functionality of an ambulance service dedicated to emergency obstetric care (EmOC) that referred pregnant women to health centers for delivery assistance or to a hospital for the management of obstetric complications.
METHODS: A retrospective study investigated an ambulance referral system for EmOC in a rural area of Ethiopia between July 1 and December 31, 2013. The service was available 24h a day and was free of charge. Women requesting referral were transported to nearby health centers. Assistance was provided locally for uncomplicated deliveries. Women with obstetric complications were referred from health centers to a hospital.
RESULTS: A total of 528 ambulance referrals were recorded. The majority of patients (314 [59.5%]) were transported from villages to health centers. The remaining individuals were brought to a hospital, having been referred from health centers (179 [33.9%]) or were referred directly from villages owing to hospital proximity (35 [6.6%]). Of the 179 patients referred to the hospital from health centers, 84 (46.9%) were diagnosed with major direct obstetric complications. No maternal deaths were recorded among patients using the ambulance service. The cost of the ambulance service was US$ 18.47 per referred patient.
CONCLUSIONS: An ambulance service dedicated to EmOC that interconnected health centers and a hospital facilitated referrals and better utilized local resources.

BACKGROUND: In spite of the critical role of Emergency Obstetric Care in treating complications arising from pregnancy and childbirth, very few facilities are equipped in Kenya to offer this service. In Malindi, availability of EmOC services does not meet the UN recommended levels of at least one comprehensive and four basic EmOC facilities per 500,000 populations. This study was conducted to assess priority setting process and its implication on availability, access and use of EmOC services at the district level.
METHODS: A qualitative study was conducted both at health facility and community levels. Triangulation of data sources and methods was employed, where document reviews, in-depth interviews and focus group discussions were conducted with health personnel, facility committee members, stakeholders who offer and/ or support maternal health services and programmes; and the community members as end users. Data was thematically analysed.
RESULTS: Limitations in the extent to which priorities in regard to maternal health services can be set at the district level were observed. The priority setting process was greatly restricted by guidelines and limited resources from the national level. Relevant stakeholders including community members are not involved in the priority setting process, thereby denying them the opportunity to contribute in the process.
CONCLUSIONS: The findings illuminate that consideration of all local plans in national planning and budgeting as well as the involvement of all relevant stakeholders in the priority setting exercise is essential in order to achieve a consensus on the provision of emergency obstetric care services among other health service priorities.

OBJECTIVE: To explore the role of a community-based intervention in reducing delays in accessing emergency obstetric care (EmOC) in rural Bangladesh, and the factors associated with delayed decision making, reaching the health facility and receiving treatment.
METHODS: Quasi-experimental study.
METHODS: Multistage random sampling was used to select 540 villages, from which 1200 women who reported obstetric complications in March-April 2010 were interviewed.
RESULTS: The median time taken to make the decision to access health care was significantly lower in the intervention areas compared with the control areas (80 vs 90 min). In addition, the median time taken to reach the health facility was significantly lower in the intervention areas compared with the control areas (110 vs 135 min). However, no difference was found in the median time taken to receive treatment. Multiple linear regressions demonstrated that the community intervention significantly reduced decision making and time taken to reach the health facility when accessing EmOC in rural Bangladesh. However, for women experiencing haemorrhage, the delays were longer in the intervention areas. Protective factors against delayed decision making included access to television, previous medical exposure, knowledge, life-threatening complications during childbirth and use of a primary health facility. Financial constraints and traditional perceptions were associated with delayed decision making. Complications during labour, use of a motorized vehicle and use of a primary health facility were associated with faster access to EmOC, and poverty, distance, transportation difficulties and decision made by male guardian were associated with slower access to EmOC.
CONCLUSIONS: The intervention appeared to reduce the time taken to make the decision to access health care and the time taken to reach the health facility when accessing EmOC. This study provides support for a focus on emergency preparedness for timely referral from the community.