The purpose of this study was to describe and evaluate the strategies used to reduce maternal mortality of the Fezile Dabi District in the Free State Province, South Africa. A quantitative descriptive study was conducted at three hospitals to describe and evaluate the strategies. Data collection was done by using the Maternal and Neonatal Programme Effort Index (MNPI) self-administered questionnaire. The study population comprised of 71 (midwives (52), doctors (13), management-operational managers (6). The overall response rate for the three hospitals was (43.5%). The study indicated that programme efforts for maternal health are similar across the three hospitals, however, there are particular areas in each hospital that need more attention. The ratings of all the strategies generally showed weak to partial effort. The findings revealed general poor performance under the following strategies: postpartum care, training arrangements, information, education, communication and hospital protocols. Based on the study results, the quality of maternal health care need to be improved / Health Studies / M. A. (Public Health)

Introdução: A mortalidade materna é um grande problema de Saúde Pública no Brasil e no mundo. Atinge muitas mulheres e representa um indicador de pobreza e iniquidade social. Objetivo: Analisar as mortes maternas ocorridas no município de São Paulo em uma série histórica de 2000 a 2008. Métodos: Estudo ecológico, que analisou os óbitos maternos ocorridos em residentes do município de São Paulo entre os anos de 2000 a 2008. Foram utilizados dados das Declarações de Óbito e dos relatórios do Comitê de Mortalidade Materna. O mapa de exclusão/inclusão social e as áreas homogêneas dos 96 distritos administrativos foram utilizados como unidades de análise. Foram calculadas as razões de mortalidade materna, o percentual de subnotificação de causas maternas declaradas e fator de correção. Foram analisadas as causas que ocultavam os óbitos maternos. A análise de tendência da mortalidade para o município foi realizada por meio de modelos de regressão polinomial e a para análise de correlação utilizou-se o teste de correlação de Pearson. Foi considerado o nível de significância de 5 por cento (p<0,05). Para análise do preenchimento das variáveis 43 e 44, as Declarações de óbito foram localizadas no arquivo morto da Prefeitura Municipal. Resultados: Ocorreram 877 óbitos. A Razão de Mortalidade Materna (RMM) foi de 53,2 óbitos/100.000 Nascidos Vivos. A série histórica apresentou tendência decrescente estatisticamente significativa, com redução de 1,73 ao ano. As menores RMM foram encontradas nas áreas homogêneas de menor exclusão social, e as maiores, nas áreas de maior exclusão. As áreas mais excluídas apresentaram risco de morte materna aproximadamente três vezes maior que na área menos excluída. A correlação de Pearson revelou moderada correlação negativa entre a RMM e o índice de exclusão/inclusão global (-0,37), o índice de desenvolvimento humano (-0,40) e de autonomia (-0,36). As principais causas de morte materna foram as obstétricas indiretas. O percentual médio de subnotificação das causas maternas foi de 45,38 por cento, e o fator de correção médio foi 1,83. Destacou-se o grande percentual de causas mal definidas declaradas. Entre 2004 a 2006, 43,4 por cento das declarações apresentaram os campos 43 e 44 preenchidos corretamente. A maioria das declarações apresentou três diagnósticos informados. Conclusões: A RMM mostrou relação com as condições socioeconômicas. É necessário maior investimento em treinamentos para o correto preenchimento das Declarações de óbito. É necessário a implementação mais efetiva de ações de saúde voltadas para a mortalidade materna / Background: Maternal mortality is a big problem of public health in Brazil and in the world. Affects many women and is an indicator of poverty and social inequity. Objective: To analyse maternal deaths occurred in the city of São Paulo in a series from 2000 to 2008. Methods: Ecologic study, which analyzed maternal deaths that occurred among residents of city of São Paulo during the years 2000 to 2008. Data were used from deaths certificates and reports of the Committee on Maternal Mortality. The map of social inclusion/exclusion and homogeneous areas of the 96 districts were used as units of analysis. We calculated maternal mortality ratios, the percentage of underreporting of maternal causes and the correction factor. We analyzed the causes that hid maternal deaths. The analysis of trends in mortality for the city was conducted using polynomial regression models and for correlation analysis used the test of correlation of Pearson. It was considered the significance level of 5 per cent (p<0,05). For examination of completing the variables 43 and 44, the deaths certificates were located in the archive of the city. Results: There were 877 deaths. The Maternal Mortality Ratio (MMR) was 53,2/100.000 live births. The series showed trend decreasing statistically significant, with a decrease of 1,73 per year. The lower MMR were found in homogeneous areas with lower social exclusion and higher than areas with higher exclusion. Areas most excluded showed risk of maternal deaths about three times higher than in area less excluded. The correlation of Pearson showed moderate negative correlation between MMR and index inclusion/exclusion overall (-0,37), the index of human development (-0,40) and the index of autonomy (-0,36). The main causes of maternal deaths were obstetric indirect. The mean percentage of underreporting of maternal causes was 45,38 per cent , and the correction factor medium was 1,83. We emphasize the high percentage of illdefined causes declared. During 2004 and 2006, 43,4 per cent of the declarations presented fields 43 and 44 filled in correctly. Most declarations presented three diagnoses listed. Conclusion: The MMR showed relationship with socioeconomic conditions. It is necessary greater investment in training for correct completion of death certificates. It is necessary the implementation more effective heath actions to maternal mortality

L'objectif de cette thèse est de proposer une méthodologie statistique permettant de formuler une règle de classement capable de surmonter les difficultés qui se présentent dans le traitement des données lorsque la distribution a priori de la variable réponse est déséquilibrée. Notre proposition est construite autour d'un ensemble particulier de règles d'association appelées "class association rules". Dans le chapitre II, nous avons exposé les bases théoriques qui sous-tendent la méthode. Nous avons utilisé les indicateurs de performance usuels existant dans la littérature pour évaluer un classifieur. A chaque règle "class association rule" est associée un classifieur faible engendré par l'antécédent de la règle que nous appelons profils. L'idée de la méthode est alors de combiner un nombre réduit de classifieurs faibles pour constituer une règle de classement performante. Dans le chapitre III, nous avons développé les différentes étapes de la procédure d'apprentissage statistique lorsque les observations sont indépendantes et identiquement distribuées. On distingue trois grandes étapes: (1) une étape de génération d'un ensemble initial de profils, (2) une étape d'élagage de profils redondants et (3) une étape de sélection d'un ensemble optimal de profils. Pour la première étape, nous avons utilisé l'algorithme "apriori" reconnu comme l'un des algorithmes de base pour l'exploration des règles d'association. Pour la deuxième étape, nous avons proposé un test stochastique. Et pour la dernière étape un test asymptotique est effectué sur le rapport des valeurs prédictives positives des classifieurs lorsque les profils générateurs respectifs sont emboîtés. Il en résulte un ensemble réduit et optimal de profils dont la combinaison produit une règle de classement performante. Dans le chapitre IV, nous avons proposé une extension de la méthode d'apprentissage statistique lorsque les observations ne sont pas identiquement distribuées. Il s'agit précisément d'adapter la procédure de sélection de l'ensemble optimal lorsque les données ne sont pas identiquement distribuées. L'idée générale consiste à faire une estimation bayésienne de toutes les valeurs prédictives positives des classifieurs faibles. Par la suite, à l'aide du facteur de Bayes, on effectue un test d'hypothèse sur le rapport des valeurs prédictives positives lorsque les profils sont emboîtés. Dans le chapitre V, nous avons appliqué la méthodologie mise en place dans les chapitres précédents aux données du projet QUARITE concernant la mortalité maternelle au Sénégal et au Mali. / The aim of this thesis is to design a supervised statistical learning methodology that can overcome the weakness of standard methods when the prior distribution of the response variable is unbalanced. The proposed methodology is built using class association rules. Chapter II deals with theorical basis of statistical learning method by relating various classifiers performance metrics with class association rules. Since the classifier corresponding to a class association rules is a weak classifer, we propose to select a small number of such weak classifiers and to combine them in the aim to build an efficient classifier. In Chapter III, we develop the different steps of the statistical learning method when observations are independent and identically distributed. There are three main steps: In the first step, an initial set of patterns correlated with the target class is generated using "apriori" algorithm. In the second step, we propose a hypothesis test to prune redondant patterns. In the third step, an hypothesis test is performed based on the ratio of the positive predictive values of the classifiers when respective generating patterns are nested. This results in a reduced and optimal set of patterns whose combination provides an efficient classifier. In Chapter IV, we extend the classification method that we proposed in Chapter III in order to handle the case where observations are not identically distributed. The aim being here to adapt the procedure for selecting the optimal set of patterns when data are grouped data. In this setting we compute the estimation of the positive predictive values as the mean of the posterior distribution of the target class probability by using empirical Bayes method. Thereafter, using Bayes factor, a hypothesis test based on the ratio of the positive predictive values is carried out when patterns are nested. Chapter V is devoted to the application of the proposed methodology to process a real world dataset. We studied the QUARITE project dataset on maternal mortality in Senegal and Mali in order to provide a decision making tree that health care professionals can refer to when managing patients delivering in their health facilities.

Submitted by Rosivalda Pereira (mrs.pereira@ufma.br) on 2017-05-19T18:15:54Z No. of bitstreams: 1 AleciaMariaSilva.pdf: 1720159 bytes, checksum: 83f9ac635ea23bbd7925f09ceff83e20 (MD5) / Made available in DSpace on 2017-05-19T18:15:54Z (GMT). No. of bitstreams: 1 AleciaMariaSilva.pdf: 1720159 bytes, checksum: 83f9ac635ea23bbd7925f09ceff83e20 (MD5) Previous issue date: 2016-09-22 / Introduction: The Maternal Mortality (MM) is a problem of public health in several countries. It represents a grave violation of the human rights and of women’s reproductive functions. Its statistics points out the level of women’s and population’s health in general. Although efforts have been implemented to its reduction, most of the countries still have high values of maternal mortality, including Brazil. It presents important variations among the regions and cities of the country. Objective: To analyse the maternal mortality and its distribution in Sanitary Districts of São Luís - MA in the period from 2003 to 2013. Methodology: Descriptive study performed by means of secondary data of the Mortality Information System (SIM) and Information System of Living Born One (Sinasc) available electronically through the site of the through the Computing Department of the Brazilian National Health System (SUS; Datasus). Results: it was analyzed 201 deaths of women residents in São Luís - MA, present in 07 sanitary districts of the city. It was observed a major perceptual of deaths among singles (women) (64.1%), dark ones (51.7%), between 20 and 29 years old (51.7%) and with 8 to 11 years of schooling (39,3%), being the majority by direct causes (62.7%), detaching the years 2007 and 2010 as the ones of major death event. The reason for maternal mortality was bigger than that one of the state of Maranhão and Brazil. Among the sanitary districts Tirirical detached itself for its major number of deaths (13.9%) besides the Itaqui-Bacanga (12.9%) and Cohab (12.0%) being by direct causes. The puerperium was the period under a major number of deaths. Conclusion: We observed that São Luís presented higher values as yet of Maternal Mortality, not being possible to reach the fifth aim of the goals of the millennium. The not informed data were present under high perceptual so showing clearly the need of a better data register in the death declarations. The Primary Health Care must be strengthened, so getting high their percentage of coverage, making systematized actions of that level of attention as to the maternal health, for effective services of prenatal care offered in the ESF of the different Sanitary Districts can represent an important intervention for the increase of the mother’s health and, extensively, of the whole population. / Introdução: A Mortalidade Materna (MM) é um problema de saúde pública em vários países. Representa grave violação dos direitos humanos e reprodutivos das mulheres e que suas estatísticas indicam o nível de saúde de mulheres e da população em geral. Embora esforços venham sendo implementados para sua redução, a maioria dos países ainda têm valores elevados de mortalidade materna, inclusive o Brasil, o qual apresenta variações importantes entre suas regiões e cidades. Objetivo: Analisar a mortalidade materna e sua distribuição nos Distritos Sanitários de São Luís-MA no período de 2003 a 2013. Metodologia: Estudo descritivo realizado com dados secundários do Sistema de Informação de Mortalidade (SIM) e Sistema de Informação de Nascido Vivo (Sinasc) disponíveis eletronicamente através do site do Departamento de Informática do SUS (Datasus). Resultados: Foram analisados 201 óbitos de mulheres residentes em São Luís-MA, presentes em 07 distritos sanitários da cidade. Observou-se maior percentual de óbitos em mulheres solteiras (64,1%), pardas (51,7%), entre 20 e 29 anos de idade (51,7%) e com 8 a 11 anos de estudo (39,3%) sendo a maioria por causas diretas (62,7%), destacando os anos de 2007 e 2010 como os de maior ocorrência de óbito. A razão de mortalidade materna foi maior do que a do Estado do Maranhão e do Brasil. Entre os distritos sanitários, o Tirirical se destacou com o maior número de óbitos (13,9%) além do Itaqui-Bacanga (12,9%) e Cohab (12,0%) sendo por causas diretas. O puerpério foi o período com maior número de óbitos. Conclusão: Observamos que São Luís apresentou valores ainda elevados de mortalidade materna, não sendo possível alcançar a quinta meta dos objetivos do milênio. Os dados não informados estiveram presentes com percentuais elevados evidenciando a necessidade de se melhorar registro dos dados nas declarações de óbito. A atenção básica precisa ser fortalecida, elevando seu percentual de cobertura e sistematizando ações nesse nível de atenção em relação a saúde materna, pois efetivos serviços de pré-natal oferecidos pela ESF nos diferentes Distritos Sanitários representam uma importante intervenção para a melhoria da saúde materna e, por extensão, de toda a população.

Eugenics movements developed early this century in more than 20 countries, including Australia. However, for many years the vast literature on eugenics focused almost exclusively on the history of eugenics in Britain and America. While some aspects of eugenics in Australia are now being documented, the history of this movement largely remained to be written. Australians experienced both fears and hopes at the time of Federation in 1901. Some feared that the white population was declining and degenerating but they also hoped to create a new utopian society which would outstrip the achievements, and avoid the poverty and industrial unrest, of Britain and America. Some responded to these mixed emotions by combining notions of efficiency and progress with eugenic ideas about maximising the growth of a white population and filling the "empty spaces". It was hoped that by taking these actions Australia would avoid "racial suicide" or Asian invasion and would improve national fitness, thus avoiding "racial decay" and starting to create a "paradise of physical perfection". This thesis considers the impact of eugenics in Australia by examining three related propositions: 1. that from the 1910s to the 1930s, eugenic ideas in Australia were readily accepted because of concerns about declining birth rate; 2. that, while mainly derivative, Australian eugenics had several distinctive Australian qualities; 3. that eugenics has a legacy in many disciplines, particularly family planning and public health. This examination of Australian eugenics is primarily from the perspective of the people, publications and organisations which contributed to this movement in the first half of this century. In addition to a consideration of their achievements, reference is also made to the influence which eugenic ideas had in such diverse fields as education, immigration, law, literature, politics, psychology and science.

Maternal mortality is a global health concern but inequalities in utilization of maternal health care are not clearly understood. Severe morbidity (near-miss) is receiving increased attention due to methodological difficulties in maternal mortality studies. The present thesis seeks to increase understanding of factors that impede utilization of emergency obstetric care (EmOC) in Bolivia and Guatemala. Studies I and IV employed qualitative interviews to explore the role of traditional birth attendants (TBAs) and the care-seeking behaviour of women who arrived at hospital with a near-miss complication. Studies II–III documented maternal mortality and near-miss morbidity at the hospital level and investigated the influence of socio-demographic factors and antenatal care (ANC) on near-miss upon arrival. The studies identified unfamiliarity with EmOC among TBAs and a lack of collaboration with formal care providers. A perception of being dissociated from the health care system and a mistrust of health care providers was common among near-miss women from disadvantaged social backgrounds. In the Bolivian setting, 187 maternal deaths per 100,000 live births and 50 cases of near-miss per 1000 were recorded. Causes of near-miss differed from those of maternal deaths. Most women with near-miss arrived at hospital in critical condition: severe preeclampsia, complications after childbirth at home and abortions were mostly encountered among them. Lack of ANC, low education, and rural residence were interactively associated with near-miss. ANC reduced socio-demographic differentials for near-miss. Complementing maternal mortality reviews with data on near-miss morbidity increases the understanding of priority needs and quality of maternal health care. Additionally, focusing on near-miss upon arrival was found useful in exploring pre-hospital barriers to EmOC. The findings identified subgroups of women who seemed especially vulnerable to pre-hospital barriers. They also underscored the need for initiatives to reduce the effect of social marginalization and to acknowledge the influential role of formal and informal care providers on the utilization of EmOC. / La mortalidad materna es un tema de inquietud global, sin embargo la comprensión de las desigualdades en la utilización de los servicios de salud materna es limitada. La morbilidad obstétrica severa (near-miss) está recibiendo creciente atención, producto de problemas metodológicos en los estudios de mortalidad materna. El objetivo de la presente tesis es aumentar la comprensión de factores que impiden la utilización de la atención obstétrica de emergencia en Bolivia y Guatemala. Los estudios I y IV usaron metodologías cualitativas en un esfuerzo por explorar el rol de las parteras tradicionales y las estrategias de las mujeres que arriban a los hospitales con una morbilidad obstétrica severa. Los estudios II–III documentaron la mortalidad materna y la morbilidad obstétrica severa en el marco hospitalario e investigaron el impacto de los factores socio-demográficos y el control prenatal en la llegada a los establecimientos de salud con complicaciones severas. Los estudios identificaron la falta de familiaridad con atención obstétrica de emergencia entre las parteras tradicionales y la falta de cooperación con los profesionales de salud formales. La sensación de estar distanciadas del sistema de salud y la desconfianza hacia los profesionales de la salud eran aspectos comunes entre las mujeres de sectores marginales con experiencias de complicaciones severas. En el contexto boliviano, 187 muertes maternas por cada 100,000 nacidos vivos y 50 casos de morbilidad obstétrica severa por cada 1000 fueron registradas. Las causas de la morbilidad obstétrica severa y las muertes maternas se distinguieron. La major parte de las mujeres con morbilidad obstétrica severa llegaron al hospital en condiciones críticas: preeclampsia severa, complicaciones después de partos domiciliarios y abortos eran causas más frecuentes en esta categoría. Combinaciones del bajo nivel de educación con la falta de controles prenatales o la residencia en zonas rurales fueron asociadas con la morbilidad obstétrica severa. El control prenatal redujo diferencias socio-demográficas en lo concerniente a la morbilidad obstétrica severa. La complementación de estudios de mortalidad materna con datos sobre morbilidad obstétrica severa aumenta la comprensión de las prioridades y de la calidad en la atención de la salud materna. Además, centrándose en la morbilidad obstétrica severa a la llegada al establicimiento de salud, ha sido útil para investigar las barreras pre-hospitalarias en relación a la atención de emergencia obstétrica. Los resultados permiten identificar categorías específicas de mujeres que parecen ser especialmente vulnerables a las barreras pre-hospitalarias. Los resultados, también subrayan la necesidad de iniciativas que reduzcan los efectos de la marginalización social, y que reconozcan el importante rol que tanto el personal de salud formal como informal cumplen en la utilización de los servicios de atención obstétrica de emergencia.

Après des années d’efforts, l’Afrique Sub-saharienne n’a connu qu’une faible amélioration de ses indicateurs de santé maternelle. Assurer l’accès aux soins obstétricaux d’urgence (SOU) pour toutes les femmes est une stratégie efficace pour réduire la mortalité maternelle. Cependant, ces soins sont dispendieux et ces dépenses peuvent être « catastrophiques ». Afin d’en réduire le fardeau, le Mali a instauré la gratuité de la césarienne et un système de référence-évacuation. L’objectif de cette étude est d’examiner la prévalence et les facteurs contribuant aux dépenses catastrophiques liées aux SOU dans la région de Kayes, Mali. Elle vise aussi à étudier les conséquences socioéconomiques de ces dépenses au sein des ménages. L’étude a révélé que les dépenses lors d’urgences obstétricales sont en moyenne de 71535 FCFA (US$ 152). Entre 20.7% et 53.5% des ménages ont encouru des dépenses catastrophiques supérieures à 15% et 5% de leur revenu annuel respectivement. Les ménages de femmes sans éducation, du milieu rural et ayant souffert d’infection post-partum sont les plus à risque d’encourir des dépenses catastrophiques. La césarienne n’est pas associée à une probabilité réduite de dépense catastrophique malgré la gratuité. Faire des dépenses élevées ne garantie pas la survie de la mère puisque entre 19,4% et 47,1% des décès maternels ont encouru des dépenses catastrophiques. Enfin, les ménages s’endettent et vendent fréquemment des biens pour faire face aux dépenses ce qui créé des difficultés financières importantes à long terme. La création de nouvelles politiques de financement sera nécessaire à l’amélioration de la santé maternelle au Mali. / After years of efforts, countries in sub-Saharan Africa have seen little to no improvement in their maternal health indicators. Ensuring access to emergency obstetric care (EmOC) for all women is a strategy proven to reduce maternal mortality. However, EmOC in sub-Saharan Africa can be extremely costly and can generate ‘’catastrophic’’ expenses. In order to reduce the economic burden of EmOC in Mali, user fees for caesareans were abolished and a maternity referral-system was created. The aim of this study is to investigate the incidence of and the factors associated with catastrophic EmOC expenditure in the region of Kayes, Mali. It also aims to identify the well-being consequences of high EmOC expenses. This study brings forth the following points. Firstly, the average EmOC expenditure was 71535 FCFA (US$ 152). Secondly, between 20.7% and 53.5% of households faced catastrophic expenditures greater than 15% and 5% of their annual income respectively. Women with no education, living in rural areas and with a postpartum infection had a higher propensity of catastrophic spending. Having a caesarean was not associated with a reduced risk of catastrophic expenditures despite the abolition of user fees for caesareans. Between 19.4% and 47.1% of households of maternal deaths also had catastrophic spending. Finally, households often had to borrow money and sell assets to pay for EmOC which led to considerable long-lasting financial difficulties. As long as policies fail to protect households from catastrophic EmOC expenditures, we cannot expect to see any great progress in reducing maternal mortality in Mali.

Résumé Objectif : Identifier les facteurs institutionnels qui influencent la mortalité maternelle (MM) hospitalière dans les maternités chirurgicales au Sénégal. Méthode : cette étude est une analyse secondaire des données de la troisième Enquête Nationale sur la Couverture Obstétrico-chirurgicale au Sénégal en 2001. Les données analysées, issues des fiches d'activité des maternités, comptaient pour 38,239 admissions en obstétrique dans 19 hôpitaux et 450 décès maternels. Les taux de mortalité maternelle hospitalière (TMMH) brut et ajusté ont été utilisés comme variables dépendantes. Le TMMH ajusté sur les caractéristiques de la clientèle ('cases-mix') a été estimé pour chaque établissement de santé par la méthode de standardisation directe. Les indicateurs de la qualité des structures, de la gestion des ressources, et un score de qualité ont été utilisés comme variables indépendantes pour prédire la MM hospitalière. Les tests de Mann-Whitney et de Kruskal-Wallis ont été utilisés pour analyser l’association entre les variables indépendantes, le score de qualité et la MM. Une analyse multivariée a été utilisée pour estimer l’impact du score de qualité sur la MM, en tenant compte de la situation géographique (Dakar versus autre région).Résultats: En analyse bivariée, la présence d'anesthésiste, la disponibilité de boîtes de césarienne complète et la supervision de tous les accouchements par du personnel qualifié sont les facteurs institutionnels associés significativement à une réduction du TMMH brut. Quant au TMMH ajusté ce sont la présence de scialytique, la disponibilité du sulfate de magnésium, l'utilisation des guides de pratiques cliniques (GPC) pour la prise en charge des complications obstétricales. Le score de qualité est associé significativement au TMMH brut, y compris en analyse multivariée, mais pas au TMMH ajusté. Conclusion : La disponibilité du Sulfate de magnésium, et du scialytique pourrait contribuer à la réduction de la MM. En complément, une réorganisation adéquate des ressources pour réduire la disparité géographique rurale/urbaine est essentielle ainsi qu’une sensibilisation du personnel à l’usage des GPC. De plus, l’assistance par un personnel qualifié de tous les accouchements est nécessaire pour améliorer la qualité des soins et la prise en charge des complications obstétricales. / Abstract Objective: To identify which institutional factors are associated to the hospital maternal mortality in surgical maternities in Senegal. Method: This study is a secondary data analysis of the third National survey of the Surgical-Obstetric Coverage in Senegal in 2001. The hospital statistics data analyzed represent 38,239 admissions in obstetrics in 19 hospitals and 450 maternal deaths. The hospital maternal death rates (TMMH) crude and adjusted were used as dependent variables. The TMMH adjusted on the characteristics of the customers (`cases-mix') was estimated for each health structure by the direct standardization method. The indicators of the structure, resources management’s complexity score quality were used as independent variables to predict hospital MM. The Mann-Whitney and Kruskal-Wallis tests were used to analyze the association between independent variables, the complexity score of quality and MM. A multivariate analysis was used to estimate the impact of quality score on the MM, taking into account the geographical location (Dakar versus other region). Results: In bivariate analysis, the presence of anaesthetist, the availability of Caesarean kit and supervision of all births by trained personnel are the institutional factors significantly associated with the crude TMMH decreased. For the adjusted TMMH, the presence of Scialytic, the availability of Magnesium Sulphate, the use of clinical guidelines of good practice (GPC) for obstetrical complications are the institutional factors associated to his decreased. The complexity score quality is significantly associated with the crude TMMH, including multivariate analysis, but not with adjusted TMMH. Conclusion: The availability of the Magnesium Sulphate, and the Scialytic could contribute to the reduction of maternal mortality. In addition, an adequate reorganization of the resources to reduce the geographical rural/urban disparity is essential, as well as a developing the personnel’s awareness for the use of GPC. Moreover, qualified assistance at birth for all women is necessary to improve the quality of care and the treatment obstetrical complications.

La mortalité maternelle et périnatale est un problème majeur de santé publique dans les pays en développement. Elle illustre l’écart important entre les pays développés et les pays en développement. Les interventions techniques pour améliorer la santé maternelle et périnatale sont connues dans les pays en développement, mais ce sont la faiblesse des systèmes de santé et les défis liés aux ressources qui freinent leur généralisation. L’objectif principal de ce travail était de mieux comprendre le rôle des ressources humaines en particulier ceux de la première ligne dans la performance d’un système de référence maternelle. Au Mali, la mise en place d’un système de référence maternelle, système de référence-évacuation « SRE », fait partie des mesures nationales de lutte contre la mortalité maternelle et périnatale. Les trois composantes du SRE, soit les caisses de solidarité, le transport et la communication et la mise à niveau des soins obstétricaux, permettent une action simultanée du côté de la demande et de l’offre de soins maternels et périnatals. Néanmoins, la pénurie de personnel qualifié a conduit à des compromis sur la qualification du personnel dans l’implantation de ce système. La région de Kayes, première région administrative du Mali, est une région de forte émigration. Elle dispose d’une offre de soins plus diversifiée qu’ailleurs au Mali, grâce à l’appui des Maliens de l’extérieur. Son SRE offre ainsi un terrain d’études adéquat pour l’analyse du rôle des professionnels de première ligne. De façon plus spécifique, ce travail avait pour objectifs 1) d’identifier les caractéristiques des équipes de soins de première ligne qui sont associées à une meilleure performance du SRE en termes de survie simultanée de la mère et du nouveau-né et 2) d’approfondir la compréhension des pratiques de gestion des ressources humaines, susceptibles d’expliquer les variations de la performance du SRE de Kayes. Pour atteindre ces objectifs, nous avons, à partir du cadre de référence de Michie et West modélisé les facteurs liés aux ressources humaines qui ont une influence potentielle sur la performance du SRE de Kayes. L’exploration des variations du processus motivationnel a été faite à partir de la théorie de l’attente de Vroom. Nous avons ensuite combiné une revue de la littérature et un devis de recherche mixte (quantitative et qualitative). Les données pour les analyses quantitatives proviennent d’un système d’enregistrement continu de toutes les urgences obstétricales (GESYRE : Gestion du Système de Référence Évacuation mis en place depuis 2004 dans le cadre du suivi et de l’évaluation du SRE de Kayes) et des enquêtes à passages répétés sur les données administratives et du personnel des centres de santé. Un modèle de régression biprobit a permis d’évaluer les effets du niveau d’entrée dans le SRE et des équipes de soins sur la survie jointe de la mère et du nouveau-né. A l’aide d’entrevues semi-structurées et d’observations, nous avons exploré les pratiques de gestion des personnes dans des centres de santé communautaires « CScom » sélectionnés par un échantillonnage raisonné. Les résultats de ce travail ont confirmé que la main d’œuvre humaine demeure cruciale pour la performance du SRE. Les professionnels de première ligne ont influencé la survie des femmes et des nouveau-nés, à morbidités égales, et lorsque la distance parcourue est prise en compte. La meilleure survie de la mère et du nouveau-né est retrouvée dans les cas d’accès direct à l’hôpital régional. Les femmes qui sont évacuées des centres de première ligne où il y a plus de professionnels ou un personnel plus qualifié avaient un meilleur pronostic materno-fœtal que celles qui ont consulté dans des centres qui disposent de personnel peu qualifié. Dans les centres de première ligne dirigés par un médecin, des variations favorables à la performance comme une implication directe des médecins dans les soins, un environnement de soins concurrentiel ont été retrouvés. Concernant les pratiques de gestion dans les centres de première ligne, les chefs de poste ont mis en place des incitatifs pour motiver le personnel à plus de performance. Le processus motivationnel demeure toutefois très complexe et variable. La désirabilité de bons résultats des soins (valence) est élevée pour tous les professionnels ; cependant les motifs étaient différents entre les catégories de personnel. Par ailleurs, le faible niveau d’équipements et la multiplicité des acteurs ont empêché l’établissement d’un lien entre l’effort fourni par les professionnels et les résultats de soins. Cette compréhension du rôle des professionnels de première ligne pourra aider le personnel administratif à mieux cibler le monitorage de la performance du SRE. Le personnel de soins pourra s’en servir pour reconnaitre et appliquer les pratiques associées à une bonne performance. Dans le domaine de la recherche, les défis de recherche ultérieurs sur les facteurs humains de la performance du SRE seront mieux identifiés. / Although proven effective interventions have been transferred from the developed world, developing countries still face high maternal and perinatal deaths. Weak health systems and human resources crisis hinder the scaling up of those interventions. This study is aimed at improving the understanding of the role of human resources, especially the first line staff in a maternal referral system, the evacuation and referral system (ERS) of Kayes (Mali). The implantation of the ERS as part of major strategies for fighting maternal and perinatal deaths has been generalised in Mali’s eight administrative regions. The ERS main components are: upgrading of emergency obstetric care (EmOC); funding by a solidarity fund; and improving transport and communication by ambulance. These components allows for joint action regarding the supply and the use of maternal and perinatal services. Yet, due to the shortages in skilled birth attendants, the extension of the coverage in emergency obstetric services has been made with less qualified staff. Kayes is Mali’s first administrative region and a cradle of emigration. It therefore offers, with the support of its immigrants, a more diversified primary care provision than elsewhere in Mali. This gives an opportunity of studying the role of primary care staff in the ERS performance. More precisely, the objectives of this research were to: 1 identify characteristics of primary care teams that influenced the ERS performance assessed by the joint mother-child survival and 2) improve the understanding of human resources practices associated with ERS performance. We combined a systematic literature review with a mixed quantitative and qualitative research design. Kayes ERS performance was modelised using Michie and West conceptual framework and the motivational process was explored with Vroom’s expectancy theory. Data for the quantitative analyses derived from an ongoing system of registering all obstetric emergencies implemented since 2004 (GESYRE: Gestion du Système de Référence Évacuation / Management of the Evacuation Referral System) and periodic surveys. A biprobit regression model has been fitted to estimate the effects of the point of entry in the ERS and the primary care team composition on the joint mother-newborn survival. We also conducted semi structured interviews and non participant observations in order to explore human resources practices in purposely selected community health centers. This research confirmed the importance of human resources in ERS performance. When women’ individual risk factors are controlled for, there is a combined effect of distance traveled and the point of entry in the ERS on one side and the community health centers staff on the other hand, on the mother-child joint survival. The best prognosis of care was found in women who directly accessed care at the regional hospital. Having been transferred from a community health center where there is a physician or more than three professionals increased the mother-child survival probability. Physicians in community health centers develop strategies for a better performance of the health centers they managed: direct implication in care and a competitive care environment. Primary care managers set up incentives to motivate staff. The motivation process remains however a variable and complex one. The desirability of good results was common for all staff though its motivations varied according to the type of staff. Besides, due to insufficiency of material and multiples intermediate factors, perception of a linkage between effort and result was low. This increased understanding of the role of primary care human resources in the ERS performance would focus the management of ERS performance on targeted but effective interventions. The workforce could benefit from the study conclusions in identifying and applying best practices. Further research challenges would also be more precisely identified.

Afin de lutter contre la mortalité maternelle dont les taux restent encore élevés avec 401 pour 100 000 naissances vivantes en 2005, le Sénégal a mis en œuvre dans la continuité de ses stratégies novatrices de délégation de compétences pour renforcer l’accès aux soins obstétricaux et néonataux d’urgence, un programme alternatif de formation au D.E.S de Gynécologie et Obstétrique de médecins généralistes basés dans les zones éloignées. A partir du curriculum du programme classique, ce programme allie l’enseignement à distance à l’aide des Nouvelles Technologies de l’Information et de la Communication, des stages pratiques dans les sites du CHU, le coaching par les enseignants du CHU dans les Centres de santé où officient les médecins apprenants, des évaluations en ligne et les évaluations annuelles formelles du programme de formation classique. Il a été mis en œuvre dans deux districts du Sénégal par la Chaire de Gynécologie et d’Obstétrique du CHU de Dakar. Ce travail présente l’évaluation à mi-parcours de ce programme en analysant son implantation et ses effets à travers une étude de cas, grâce à des données qualitatives et quantitatives. Les résultats montrent : une évolution favorable des indicateurs sanitaires dans les deux sites du programme comparativement aux sites témoins, une augmentation du niveau de connaissance et de compétence des apprenants, et un niveau de satisfaction élevé des deux apprenants, des enseignants et des bénéficiaires. Cependant, des améliorations sont à apporter dans la mise en œuvre du programme en particulier en termes d’opérationnalisation des innovations pédagogiques, de coordination et de pérennisation par le Ministère de la Santé. / In order to reduce high level of maternal mortality rate estimated in 2005 at 401/100 000 live births, and following task shifting innovative strategies already initiated in the country to increase access to emergency obstetric care in Senegal, an alternative training program has been implemented for general medical doctors working in remote areas, to be effective obstetricians gynecologists. Adapted from the normal curriculum, this program combines distance learning using new information and communication technology, practical training in university facilities, coaching and mentoring by university teachers in learners’ heath centers, on line evaluations and also formal annual evaluations such as the normal program. The program has been implemented in two districts in Senegal by Obstetrics and Gynecology Unit of Dakar University. This midterm evaluation analyzes the program implementation and effects using case study with qualitative and quantitative data. Results show a positive evolution of emergency obstetric care indicators compared with two control districts, an increased level of trainees’ knowledge and skills, and also satisfaction of trainees, trainers and beneficiaries. However, some weaknesses have been identified in the program implementation particularly regarding implementation of new training innovations, coordination and sustainability by Ministry of Health.