Introduction A caesarean section is a major obstetric procedure that can save the life of mother and child. Its purpose is to protect the mother’s health from the complications of childbirth and to protect the baby’s health. In sub-Saharan Africa (SSA), there are major inequalities in access to caesarean sections and significant variations in practices to determine the indications for the procedure. Periodic analyses of maternal deaths have shown that more than half of maternal and new born deaths are due to suboptimal care and are therefore potentially preventable. The objective of our study is to assess the impact of health staff training under the PADISS project (to support the health system’s integrated development) on the quality of CS procedures in North Kivu, by comparing two periods. Material and methods The populations compared were recruited from the referral hospitals in North Kivu, DRC (Democratic Republic of Congo). The first (group 1) was made up of patient files studied retrospectively for the period from 01/11/2013 to 01/01/2016. The second group (group 2), studied prospectively, comprised patient files from June 2019 to January 2020. Obstetric, maternal and foetal data were compared. Statistical analyses were performed using STATA/IC 15.0 for Windows. Univariate and multiple logistic regression was performed to determine which characteristics are associated with maternal and perinatal morbidity and mortality. A p value < 0.05 was considered statistically significant. Results CS frequency was approximately 17% in both study periods. We observed a CS frequency of about 34% at North Kivu provincial hospital for the two populations studied. The main indications for CS were dystocia, foetal distress and scarred uterus for both populations. In the population studied prospectively, after the implementation of health staff training, there were fewer incidence rate of dystocia, foetal distress and neonatal death, a more complete patient record, shorter hospital stay, and fewer blood transfusions but more incidence rate of scarred uterus, post-operative complications and low birth weight. Intervention had no statistically significant impact on low birth weight (OR = 1.9, p = 0.13), on neonatal mortality (OR = 0.69, p = 0.21). Conclusion Our study shows a decrease in neonatal deaths, dystocia and foetal distress, but an increase in post-operative complications, maternal deaths and cases of scarred uterus and low birth weight. However, multiple logistic regression did no support the conclusion.
The first, baseline population was recruited from referral hospitals in the city of Goma from the period 01/11/2013 to 01/01/2016 (group 1). It is a retrospective, descriptive and analytical study concerning all CS performed across all deliveries that occurred during the period under study [10]. Twin pregnancies were excluded from the study. The medical staffs in each hospital were capable of performing a CS. A data collection form was designed. Data collection was carried out by a team of investigators made up of doctors and midwives in these maternity units. The sources of information were the delivery record, partograph, surgical reports and neonatal records. The sociodemographic parameters (maternal age, marital status, level of education, ethnicity, occupation, primary residence, weight, height), medical and surgical history, obstetric environment (antenatal monitoring), and maternal and perinatal morbidity and mortality (complications and outcome) were analyzed. The data collection was anonymous for the retrospective study after the agreement of the provincial authority. For the prospective study, consent was verbal, free and informed after explaining the objectives of this research. After analysis of our retrospective study, cesarean section was not a factor in reducing maternal and perinatal morbidity and mortality, hence the benefit of improving working conditions at the level of referral centers, transfert conditions, basic infrastructure and caregiver training. Following these findings, specific training was given to the local health staff. The training was based around theory and clinical activities that were carried out during our various visits in order to increase the skills of the gynaecologists, obstetricians and midwives in the different health zones in North Kivu. This training was delivered by the team of gynaecologists, obstetricians, paediatricians, anaesthetists, hygienists, midwives and theatre nurses at Erasme hospital in Brussels as part of the PADISS project. For the theory activities, several seminars were held on the pedagogical elements with a continuing education frame of reference, on the organisation of clinical audits, the preparation of treatment protocols with all the gynaecologists and members of the provincial health department (DPS), the preparation of different themes for the continuing education, such as gestational hypertension, gestational diabetes, the management of antenatal and post-partum hemorrhage, caesarean section and its alternatives, echography in gynaecology and obstetrics, antenatal consultations, monitoring during labour, the use of obstetric manoeuvres, hospital hygiene, the maintenance of medical files, and neonatal care. The gynaecologists, obstetricians, midwives and maternity-paediatric nurses from these various health zones attended these non-certificate courses on a daily basis. For the clinical activities, the objective was to provide technical support to medical and midwifery trainers, establish the pedagogical method for the training linking the frame of reference and the different activities, and carry out individual skills assessments. The clinical activities were based around ward rounds with trainee doctors and by the provincial trainer, participation in gynaecological and obstetrical consultations, the approach to paraclinical tests taking into account the situation on the ground, assistance in the operating theatre and delivery room, as well as teaching obstetric maneuvers to all health staff using simulations on a manikin. A second population (group 2) was therefore selected prospectively in order to assess the benefit of the training provided. The training started from February 2016 until March 2020. The various teams of gynecologists, pediatricians, anesthesiologists, health doctors, midwives, nurses in the operating room had carried out several missions in the field. Each mission was for an average duration of 10 days, 8 hours of theoretical and practical training per day. The second group was recruited from the same hospitals in Goma for the period from June 2019 to January 2020 (group 2). This was a prospective, analytical, cross-disciplinary study concerning all CSs performed across all deliveries (2094) that occurred during the period under study. Twin pregnancies were excluded from the study. All the women who had a CS in the hospitals were included exhaustively in the study. Data collection was carried out by a team of investigators made up of doctors and midwives in these maternity units. The sources of information were the delivery record, partograph, surgical reports and neonatal records. The sociodemographic parameters (maternal age, marital status, level of education, ethnicity, occupation, primary residence, weight, height), medical and surgical history, obstetric environment (antenatal visits), and maternal and perinatal morbidity and mortality (complications and outcome) were analyzed and compared with group 1. The findings are reported as a percentage for the categorical variables, as average and standard deviation (SD) or median and interquartile range [25%-75%] for the quantitative variables depending on their respective distribution, Gaussian or otherwise. The categorical variables were compared between the two groups using the Chi2 Pearson test, or Fisher’s exact test for a small sample. The quantitative variables were compared using the Mann Whitney test depending on their respective distribution, Gaussian or otherwise. Univariate and multiple logistic regression was used to study the association between our variables (socio-demographic, medical and obstetric) and three other variables (low birth weight, neonatal mortality and post-operative complications). The variables with a high percentage of missing values were not included in the univariate analysis. The variables included in our multiple logistic regression model were selected according to the statistical association (p ≤ 0.05) with the result of the univariate analysis, and to the total number of cases. The odds ratios and their 95% confidence intervals were calculated using each variable coefficient (and standard errors) in the model. The significance of each coefficient was tested using the Wald test. The Hosmer and Lemeshow test was used to verify the model’s goodness of fit. A value of p < 0.05 was considered statistically significant. Statistical analyses were performed using STATA/IC 16.0 for Windows. Ethic statement: The provincial health division of North-Kivu in the democratic Republic of Congo does not have an ethics commitee. Authorization to conduct this research was obtained by the same provincial authority that had waived informed consent for the retrospective study. The data in this retrospective study was anonymised. For the prospective study, patients had given their informed verbal consent for data from their medical records to be used for research.
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