Caesarean section as preferred mode of delivery in term breech presentations is not a realistic option in rural Zimbabwe.

We undertook this retrospective cross-sectional study in order to establish the outcome of 510 singleton breech presentations at term in seven district hospitals in rural Matabeleland-North Province, Zimbabwe. We also studied the mortality for 1093 caesarean sections (CS), in order to decide if CS should be the preferred option for breech births. The perinatal mortality rate in singleton breech presentation (BrPNMR) was very high:166/1000. Between the hospitals the BrPNMR ranged from 66 to 225/1000 (P = 0.04). Although the outcome was better for CS than for vaginal delivery (odds ratio = 5.4, P = 0.0005), there was no correlation between the BrPNMR and the CS rate. Results indicate that closer monitoring of these high-risk pregnancies by the most senior staff would be more effective than increasing the number of CS performed. An external cephalic version at term could also reduce breech-related mortality. Symphysiotomy is a life-saving emergency intervention when the head is trapped. Increasing the number of CS should be strongly discouraged since the case fatality rate in this rural setting was found to be very high: 18/1093 women died after CS (for any indication) within 42 days after the operation (1, 6%); 15 within 24 h. Haemorrhage was the major cause of death.

The challenge of measuring quality of care at health centre level in Africa: the example of Tsholotsho health district in Matabeleland North, Zimbabwe.

This study is on the evaluation of quality of health care within first line health services in rural Zimbabwe. It took place between 2001 and 2002, and consisted of a cross-sectional survey designed to compare the quality of health care on offer at a newly created health centre with that provided by the district hospital's outpatient department. The hypothesis to be tested was that the health centre offered better quality of care. A comprehensive quality of care evaluation framework was designed. The concept of patient enablement was incorporated into the study's assessment of health care delivery outcomes. The results did not provide conclusive evidence that the care offered at the health centre was better than the care on offer at the hospital OPD. The reasons for these unexpected findings are discussed in depth. They are related to the limited understanding amongst local health workers of the organisational changes introduced by the District Health Executive (DHE), together with a (European) cultural bias in the quality of care model under test. An important lesson of this study is that the notion of enablement, notwithstanding the need to put into context the tools used to measure it, was considered by the DHE as relevant in the organisation and evaluation of health care.