[Maternal mortality audits in low-resource countries: analysis of 23 hospitals in Senegal and Mali (the QUARITE study)]. / Audits de décès maternels dans les pays à faibles ressources: analyse d'implantation dans 23 établissements de santé au Sénégal et au Mali (essai QUARITE).

BACKGROUND: In 1990, the Society of Obstetricians and Gynaecologists of Canada joined the international movement for safe motherhood by adapting its ALARM programme to the needs of low-resource countries. The goal of the QUARITE (QUAlité des soins, gestion du RIsque et TEchniques obstétricales) trial is to evaluate the efficiency of the ALARM International programme in terms of maternal mortality reduction in 46 referral hospitals in Senegal and Mali. OBJECTIVE: Evaluate the implementation of maternal death audits in the 23 hospitals that are part of the QUARITE trial's intervention group. METHOD: Ten follow-up indicators have been identified to evaluate the implementation of maternal death audits. This article describes and analyzes these follow-up indicators during a 5-month implementation period, from September 23, 2008, to January 30, 2009. Data was gathered during a supervision visit at the end of that period with a standardized follow-up questionnaire and checklist. Key participants were interviewed. The programme's documents (procedure manual, meeting and supervision minutes, and logbook) were analyzed. An implementation score (on a scale from 1 to 10) was calculated for each centre. RESULTS: The 23 centres we visited yielded a mean implementation score of 7.5 (minimum=4 and maximum=10). In each health structure, there is a multidisciplinary, functional subcommittee-maternal death audit committee whose members have been trained on the subject of maternal death audits. Overall, these subcommittees use the management tools but some of the forms are not well understood: thus, we must pinpoint the causes of this problem and eliminate them. Maternal death audit sessions had a slow start due to several factors: maternity personnel's workload, lack of confidence of local leaders, lack of cohesion within teams and lack of personnel availability. CONCLUSION: Data analysis indicates that the process of implementing maternal death audits is slow but real and that quarterly supervision makes it possible to eliminate difficulties and to reinforce the skills of audit subcommittee members.

Long-term reductions in mortality among children under age 5 in rural Haiti: effects of a comprehensive health system in an impoverished setting.

OBJECTIVES: Evidence regarding the long-term impact of health and other community development programs on under-5 mortality (the risk of death from birth until the fifth birthday) is limited. We compared mortality in a population served by health and other community development programs at the Hôpital Albert Schweitzer (HAS) with national mortality rates among children younger than 5 years for Haiti between 1958 and 1999. METHODS: We collected information on births and deaths in the HAS service area between 1995 and 1999 and assembled previously published under-5 mortality rates at HAS. Published national rates for Haiti served as a comparison. RESULTS: In the early 1970s, the under-5 mortality rate at HAS declined to a level three fourths lower than that in Haiti nationwide. More recently, HAS rates have remained at one half those for Haiti nationwide. Child survival interventions in the HAS service area were substantially higher than in Haiti nationwide although socioeconomic characteristics and levels of childhood malnutrition were similar in both areas. CONCLUSIONS: HAS's programs have been responsible for long-term sustained reduction in mortality among children aged less than 5 years. Integrated systems for health and other community development programs could be an effective strategy for achieving the United Nations Millennium Goal to reduce under-5 mortality two thirds by 2015.

Reducing under-five mortality through Hôpital Albert Schweitzer's integrated system in Haiti.

BACKGROUND: The degree to which local health systems contribute to reductions in under-five mortality in severely impoverished settings has not been well documented. The current study compares the under-five mortality in the Hôpital Albert Schweitzer (HAS) Primary Health Care Service Area with that for Haiti in general. HAS provides an integrated system of community-based primary health care services, hospital care and community development. METHODS: A sample of 10% of the women of reproductive age in the HAS service area was interviewed, and 2390 live births and 149 child deaths were documented for the period 1995-99. Under-five mortality rates were computed and compared with rates for Haiti. In addition, available data regarding inputs, processes and outputs for the HAS service area and for Haiti were assembled and compared. RESULTS: Under-five mortality was 58% less in the HAS service area, and mortality for children 12-59 months of age was 76% less. These results were achieved with an input of fewer physicians and hospital beds per capita than is available for Haiti nationwide, but with twice as many graduate nurses and auxiliary nurses per capita than are available nationwide, and with three cadres of health workers that do not exist nationwide: Physician Extenders, Health Agents and Community Health Volunteers. The population coverage of targeted child survival services was generally 1.5-2 times higher in the HAS service area than in rural Haiti. DISCUSSION: These findings support the conclusion that a well-developed system of primary health care, with outreach services to the household level, integrated with hospital referral care and community development programmes, can make a strong contribution to reducing infant and child mortality in severely impoverished settings.