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Introduction: In 2010, the Ministry of Health (MoH) of Guinea introduced a free emergency obstetric care policy in all the public health facilities of the country. This included antenatal checks, normal delivery and Caesarean section. Objective: This study aims at assessing the changes in coverage of obstetric care according to the Unmet Obstetric Need concept before (2008) and after (2012) the implementation of the free emergency obstetric care policy in a rural health district in Guinea. Methods: We carried out a descriptive cross-sectional study involving the retrospective review of routine programme data during the period April to June 2014. Results: No statistical difference was observed in women’s sociodemographic characteristics and indications (absolute maternal indications versus non-absolute maternal indications) before and after the implementation of the policy. Compared to referrals from health centers of patients, direct admissions at hospital significantly increased from 49% to 66% between 2008 and 2012 (p = 0.001). In rural areas, this increase concerned all maternal complications regardless of their severity, while in urban areas it mainly affected very severe complications. Compared to 2008, there were significantly more Major Obstetric Interventions for Maternal Absolute Indications in 2012 (p<0.001). Maternal deaths decreased between 2008 and 2012 from 1.5% to 1.1% while neonatal death increased from 12% in 2008 to 15% in 2012. Conclusion: The implementation of the free obstetric care policy led to a significant decrease in unmet obstetric need between 2008 and 2012 in the health district of Kissidougou. However, more research is needed to allow comparisons with other health districts in the country and to analyse the trends.
The approach and strategy of UON has already been described [9,19]. The UON indicator gives an estimate of the gap between the expected Major Obstetric Interventions (MOI) required for Absolute Maternal Indications (AMI) in given well-defined population, such as a health district (needs), and the actual delivery of these services to this population (Fig 1). (adapted from UON Tackling Unmet Need for Major Obstetric Interventions. Concepts, General Principles and International Network. ITGPress, 1999. http://www.uonn.org/pdf/Guide1.pdf) Studies using the UON approach in different contexts have taken a thresholds ranging from 1% to 2% [17, 20, 21] of total deliveries as the minimum expected number of MOI for AMI. As no previous evaluation of the UON has been conducted in Guinea, we have decided, based on the literature and experts’ advice to use the median threshold, suggested by the UON Network, of 1.4% of all deliveries for this study [14]. This was a descriptive cross-sectional study involving the retrospective review of routine programme data. With an estimated 12 million inhabitants in 2012, Guinea is a low income country where 65% of the population lives in rural areas and 55% of the population earn less than $300 per year [18, 22]. The maternal mortality ratio has decreased from 980 to 724 per 100 000 Live Births between 2005 and 2012 but still remain high while the use of contraception is low (only 7% of women of reproductive age were using modern contraceptives in 2012) [18, 23]. In 2012, the estimated number of deliveries was 435,000 and the proportion of deliveries with skilled attendant was 45.3% at national level with a wide urban/rural disparity (83.9% versus 31.6% respectively) [18]. The health district of Kissidougou covers a population of about 290,000 inhabitants [24]. The district hospital serves as the reference hospital for 17 public health centres. This hospital is the only one that provides obstetric interventions including caesarean section in the district. The free obstetric care policy consisted of free access to antenatal care, normal delivery and c-section for all women in all the public health facilities. Before this policy, hospital expenses were paid in cash by women and their families. With the free obstetric care policy launched in 2010, the MoH provided funding and equipment to the hospital and Health Centers. International medical organizations such as EngenderHealth provided additional technical and financial support to upgrade infrastructures and train the medical staff of the maternity unit as part of the Fistula Care Project [25]. In 2011, the MoH offered an emergency transportation to the district hospital as part of the policy. The hospital comprises 48 beds in three inpatient departments (paediatrics, surgery and medicine), a 27-bed maternity unit with an additional 14-bed fistula unit), an emergency service, a laboratory, dentistry and a service of Medical Imaging (x-ray). The hospital has two obstetricians, two surgeons, two midwives, two nurses and seven auxiliary health providers that run a twenty-four hour care in the delivery ward. All women who underwent obstetric intervention at the district hospital of Kissidougou between 1st January 2008 to 31 December 2008 (before) and 1st January 2012 to 31 December 2012 (after) were included in the study. Data were collected between April and June 2014. The socio-demographic and clinical characteristics of patients included age, parity, residence (rural/urban), mode of admission (direct admission/referral from health centres), and maternal indication for C-section or MOI. Maternal and neonatal health outcomes were woman alive (yes/no), child alive (yes/no), as reported in hospital medical records. C-section rate was calculated by using the number of c-section performed during the year (numerator) and the expected number of births in the same year (denominator).Unmet obstetric needs (needs of MOI–actual MOI) were computed as follows: MOI represented the number of surgical procedures performed (Fig 1) and Absolute Maternal Indication represented the diagnoses established by the health care team (Fig 1). The expected MOI for AMI was estimated using the expected number of births in the district for each year and the UON threshold of 1.4% [14]. We derived the number of MOI for AMI actually performed per year from our dataset and, we calculated the unmet need (Fig 1). Structured forms were used to extract the study-related data from patient hospital records kept at the maternity. Data collected from patient’s files was double entered by two independent encoders into a file using EpiData Entry software (version 3.1, EpiData Association, Odense, Denmark). The two data files were compared and discordances resolved by cross-checking with the paper registers. Data were analysed using STATA 13 software (STATA Corporation, College Station, TX, USA). Frequencies (%) were calculated to describe patients’ characteristics and maternal and child outcomes. Pearson’s Chi Square (χ2) and Fischer’s exact test were used to compare proportions of study outcomes between the two years. The level of significance was set at p = 0.05 with a 95% confidence intervals Ethics approval was obtained from the Guinean National Ethics Committee for Health Research and the study satisfied the ethics criteria of the MSF Ethics Review Board (Geneva, Switzerland) and the Ethics Advisory Group of the International Union Against Tuberculosis and Lung Disease, Paris, France, for studies using routinely collected programme data. This being a retrospective study in hospital setting, consent was not obtained. However, patient records/information was anonymized and de-identified prior to analysis.
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