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INTRODUCTION: The high cost of emergency obstetric care (EmOC) is a catastrophic health expenditure for households, causing delay in seeking and providing care in poor countries. METHODS: In Nouakchott, the Ministry of Health instituted Obstetric Risk Insurance to allow obstetric risk sharing among all pregnant women on a voluntary basis. The fixed premium (US$21.60) entitles women to an obstetric package including EmOC and hospital care as well as post-natal care. The poorest are enrolled at no charge, addressing the problem of equity. RESULTS: 95% of pregnant women in the catchment area (48.3% of the city's deliveries) enrolled. Utilization rates increased over the 3-year period of implementation causing quality of care to decline. Basic and comprehensive EmOC are now provided 24/7. The program has generated US$382,320 in revenues, more than twice as much as current user fees. All recurrent costs other than salaries are covered. CONCLUSION: This innovative sustainable financing scheme guarantees access to obstetric care to all women at an affordable cost.

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OBJECTIVES: 1) To measure the incidence of dystocia in six cites and one rural area in West Africa. 2) To identify risk factors of dystocia and analyze their interrelationships with the goal to potentially use them to identify high-risk pregnant women attending antenatal consultations. (3) To assess their usefulness as predictors of dystocia during pregnancy. METHODS: The MOMA study is a prospective population-based follow-up study of 20,326 pregnant women in West Africa. Due to the likely diagnostic and recall bias for home deliveries, risk factors for dystocia were analyzed only for deliveries in health facilities. A total of 16,318 deliveries were analyzed. RESULTS: The incidence of dystocia was 18.3% (95%CI: 17.7-18.9). Multivariate analysis using stepwise logistic regression disclosed the following significant risk factors: short stature, scarred uterus, nulliparity. Positive predictive values were very low for both univariate and multivariate analysis. CONCLUSION: The incidence of dystocia, which occurs mainly at delivery, is high in West Africa. Consequences are often dramatic, both for the fetus and the mother. None of the risk factors studied, even when used in combination, provided a good prediction of dystocia. All pregnant women should therefore be considered at risk of dystocia. Efforts should be made to detect dystocia during labor (partography) and to provide good-quality emergency obstetric care. Emergency obstetric care must be made available to all pregnant women. This goal can be achieved in most of the major West African cities. More facilities offering good-quality cesarean section must be made available.

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OBJECTIVE: To determine what factors related to health services in France might explain substandard care of severe morbidity due to obstetric haemorrhage. DESIGN: Retrospective questionnaire survey. SETTING: Three administrative regions of France. POPULATION: All women who were pregnant or had recently given birth during the year before the survey. METHODS: A European survey (MOMS-B) defined severe haemorrhages as blood loss > or = 1500mL. A specific questionnaire was added in France to analyse the quality of care of these haemorrhages. The survey was carried out in three different administrative regions: Champagne-Ardenne, the Centre and Lorraine. An expert committee was appointed and began by establishing a framework for qualitative assessment. One hundred and sixty-five cases of severe haemorrhage were reviewed and classified into one of three levels of care: appropriate, inadequate or mixed. Inadequate care and 'mixed' care were both considered substandard. The 165 cases were coded and then studied with uni- and multivariate analysis (logistic regression with SAS and SPSS software). RESULTS: Of the 165 cases identified, 51% (85/165) were vaginal, 19% (31/165) operative vaginal, and 30% (49/165) caesarean. The leading cause of haemorrhage was uterine atony. Overall, 62% of the cases received appropriate care, 24% received totally inadequate care and 14% mixed care. After adjustment for sociodemographic factors, antenatal care and organisational aspects, the lack of a 24-hour on-site anaesthetist at the hospital and a low volume of deliveries (<500 births per year) were the factors associated with substandard care. CONCLUSION: Organisational features are so important that application of good clinical practices for safer motherhood reinforce the need for new organisation of obstetric services. For the first time, the presence of an anaesthetist is shown to have a measurable effect on the quality of care for women giving birth. These results need to be confirmed by others.

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OBJECTIVES: To determine the incidence of dystocia in seven west African cities, to attempt to discover what, if any, factors at the prenatal visit might identify women at risk of dystocia, and to assess the utility of such screening. METHOD: This prospective population study of 20326 pregnant women in west Africa (MOMA) analyzed risk factors for dystocia on the basis of deliveries in health care facilities. RESULTS: Incidence of dystocia was 18.3%. In the multivariate analysis, the risk factors were small stature, previous cesarean, and nulliparity. As screening tools these factors have inadequate positive predictive values, either singly or combined. CONCLUSION: It is almost impossible to predict the occurrence of dystocia before the onset of labor. Therefore, labor must be carefully monitored, and there must be health care facilities available that can manage complications, especially cesarean deliveries. If such facilities are not accessible, an effective referral system must be established.

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