Study Setting: Two rural Indonesian districts served by the national midwife-in-the-village programme. Methods: Three critical incident audits of maternal mortality and severe morbidity: confidential enquiry, a verbal autopsy survey, and a participatory community-based review. Results: A range of inter-related factors contributed to poor quality and access. When delivery complications occurred, many women and families were un-informed, un-prepared, found care unavailable, unaffordable, and relied on traditional providers. Social health insurance was poorly promoted, inequitably distributed, complex, bureaucratic, and often led to lower quality care. Public midwives were scarce in remote areas and lacked incentives to provide care to the poor. Emergency transport was often unavailable and private transport incurred further expense. In facilities, there was reluctance to admit poor women, and ill-equipped, under-staffed wards for those accepted. Referrals between hospitals were also common. Examining adverse events from user and provider perspectives yielded multi-level causal explanations. These were used to develop a conceptual model relating structural arrangements (such as decentralisation, commodified care and reductions in public funding) to constrained service provision and adverse health consequences. Conclusions and recommendations: A policy shift towards healthcare as a public good may provide a route to reduce available maternal ill-health. Engaging with those who require and provide critical care in routine assessments can inform more robust health planning, and promote inclusion and participation in health.

The CanMEDS 2015 Framework outlines many key competencies that must be addressed during residency training. The move towards the “Competency by Design” curriculum will require the use of simulation for assessment of these competencies. However, the use of simulation poses many challenges for residency programs including meeting the learning needs of multiple levels of learners, financial constraints, time constraints etc. We performed a program evaluation on an obstetrical emergencies simulation curriculum that involved Obstetrics and Gynecology residency trainees (PGY1-PGY5). Different levels of learners participated in various roles including; first responder (PGY2), second responder (PGY5), confederate roles including patient, nurse or family member (PGY1-3) and assessor (PGY4). This permitted assessment of the following CanMEDS competencies: medical expert and communicator (PGY2); communicator and leader (PGY5); communicator, collaborator and health advocate (PGY1-3) and scholar (PGY4). We were able to determine financial costs, faculty time, and resident time for our existing simulation curriculum and our new simulation curriculum. Residents were surveyed prior to the simulation regarding the learning environment in our pre-existing simulation curriculum and self-efficacy ratings for the competencies mentioned above. Faculty were also surveyed prior to the simulation regarding the residents’ competencies. Station scores were collected for all competencies. Focus groups allowed further exploration of the residents’ and faculty perceptions of the new simulation experience. Lastly, post-simulation surveys of both residents and faculty allowed comparison of pre- and post- learning environment assessment and self- efficacy/performance scores. We had limited station scores from our pre-existing simulation curriculum to allow direct comparison between the specific scenarios The program evaluation determined that this method of incorporating multiple levels of learners provided a feasible and acceptable method of assessing multiple CanMEDS competencies while minimizing financial costs and significantly reducing faculty time requirements. / Thesis / Master of Science (MSc) / This study examined a simulation curriculum for obstetrical emergencies using multiple postgraduate learners in various roles, to provide a learning opportunity and assessment opportunity, for a number of skills required by the Royal College of Physicians & Surgeons of Canada. It was found that involving learners in various roles, including responders; confederates acting as nurses, patients and family members; and assessors, enhanced learning in regards to patient management, communication, collaboration, assessment and health advocacy while reducing financial costs and faculty time requirements.

BACKGROUND: Maternal mortality remains a persistent public health concern in Sub-Saharan African countries such as Ethiopia. The Ethiopian Ministry of Health has made it a priority to improve maternal health outcomes within the country. Health information technology (HIT) solutions are a flexible and low-cost method for improving health outcomes and have been proven beneficial in low-to-middle income countries, like Ethiopia. The aims of this dissertation were: (a) to characterize the use of HIT usability evaluations in Africa; (b) to quantify facility clinical readiness for obstetric emergencies; (c) to explore the obstetric emergency supply chain dynamics and information flow; (d) to create a visualization dashboard to monitor obstetric emergency readiness; and (e) to evaluate the usability of the dashboard. METHODS: This dissertation comprised six studies with a variety of quantitative and qualitative methods: (1) a scoping review of the literature to identify the types and timing of HIT evaluations occurring in Africa; (2) a prospective, cross-sectional, facility-level comparison of obstetric emergency clinical readiness in Amhara, Ethiopia as measured by the Signal Functions and Clinical Cascades methods; (3) qualitative semi-structured interviews to gain an understanding of the current supply chain in the region, communication flow, and the current barriers and facilitators to success; (4) a case study summarizing the process for the development of the dashboard prototype through integrating existing technology, current literature, and qualitative interview findings; (5) user-centered design sessions with individuals who interact with the obstetric emergency supply chain to create an electronic dashboard prototype to monitor facility readiness to manage obstetric emergencies; and (6) expert review of the dashboard including sessions with a domain expert and information visualization experts and a heuristic usability evaluation with human-computer interaction experts to evaluate and improve the ease of use and usefulness of the prototype. RESULTS: The scoping review found that many usability evaluations in Africa lacked theoretical frameworks to support their work, and that most studies occurred later in the development process when the HIT was close to implementation in practice. The quantitative analysis of facility readiness found that many facilities were missing critical supplies for managing obstetric emergencies and identified a 29.6% discrepancy between the Signal Function tracer items and the Clinical Cascades readiness classifications indicating that the former, which is recommended by the World Health Organization, overestimates facility readiness. The qualitative interviews identified several locations within the current obstetric emergency supply chain where barriers such as bridging the gap of data availability between facilities and regional hubs could be addressed to improve overall facility-level readiness and pointed towards a dashboard as a potential solution. Once a prototype dashboard was developed, user-centered design sessions refined the terminology and colors that should be used throughout the dashboard screens and identified critical graphics and data elements that users believed should be included. Following domain and visualization expert review and iterative refinement of the dashboard, human-computer interaction experts rated the dashboards highly usable. CONCLUSIONS: Dashboards are a novel method for promoting facility-level readiness to manage obstetric emergencies. By exploring the existing supply chain and including targeted end-users and experts in the design process the author was able to tailor the dashboard to meet user needs, fit into the existing integrated pharmaceutical logistics system, and ensure that it follows best practices. Consequently, these studies contribute to strategies to address maternal mortality in Ethiopia.

Maternal and newborn health is one of the main indicators of a good health system. The study wished to develop a strategy to improve the referral system for maternal and newborn care. To identify issues for improvement, the researcher explored the appropriateness of referrals, referral pathways and challenges, and provider costs for maternal and newborn care at health centres and hospitals levels. The researcher selected a sequential explanatory mixed method research design. Two primary hospitals and six health centres were purposively selected for participation. The first phase collected quantitative data by reviewing the health facilities’ medical records for services provided and health service costing, respectively. Data collection covered one Ethiopian fiscal year (8 July 2017 to 7 July 2018). Based on the existing human resource arrangement and care needs, the health service costing found that a single midwife at health centre level spent half of the expected time for delivery care. The cost estimates of various types of care delivery care indicated that delivery care at health centre and hospital levels cost $27.5 to $30.2, and $34.7 to $37.8, respectively. The primary hospitals incurred four times the cost for newborn intensive care units and Caesarean sections compared to normal delivery care. In the second phase, the researcher collected qualitative data from 26 purposively selected key informants in interviews. The findings indicated that the selected hospitals and health centres had a referral system, but several factors impeded its effective implementation. Knowledge of referral pathways determined the referral practices at the lower level of the system. The number of inappropriate referrals to primary hospitals indicated a need to mobilize and educate the community on the services available and protocols of care. In general, most referrals could have been managed at health centre level. Emergency medical transportation is a critical component of the referral system; delays in transportation determine the outcome of care at hospital level. Ambulance management was generally poor, lacked a tracking system, and was negatively affected by confusion and lack of coordination between facilities. The available ambulances were not well equipped or well-staffed for emergency management. Moreover, there were frequent breakdowns due to limited budget for maintenance and running costs. The quality of maternal care depends on the quality of the labour monitoring. However, partograph utilization was not consistently practised. Admitted cases were not properly monitored because of the high caseload and limited supervision support. In many cases, healthcare professionals tended to “treat charts” rather than promote evidencebased practice while providing care. The quality of practice was challenged by insecurity in the working environment but strengthened by good teamwork and available consultation support. The implementation of the existing referral system depended on the people involved; the use of performance indicators; follow up by management, and an accountability framework. The findings of the two phases of the study and review of other countries’ experiences on the identified problems, led to the development of draft strategy and then a consultation with relevant experts produced the final strategy. The strategy includes interventions to improve the practices at the sending and receiving facilities as well as suggestions to improve the communication, transportation and overall governance system. Then, taking into consideration all the phases of the study, the researcher makes recommendations for practice and further research. / Health Studies / D. Litt. et Phil. (Healht Studies)

The contribution of Emergency Obstetric Care (EmOC) in reducing maternal mortality in Ethiopia is very minimal as evidenced by poor provision and low utilization of EmOC. Client centred EmOC provision improves the provision and utilization of EmOC; leading to the treatment of the majority of obstetric complications which are the main causes of maternal mortality. This study describes clients’ views and perspectives concerning the quality of EmOC provision in Ethiopian public health facilities. An explorative and descriptive phenomenological qualitative study design was used in the study in order to explore and describe the lived experiences of clients with EmOC services. Key informant interviews with women who had direct obstetric complications and received EmOC at three public health facilities in Addis Ababa generated rich data on their lived experiences. Content analysis was used to analyze the data as it complies with the phenomenological data analysis and Atlas ti version 6.2 qualitative data analysis software was employed. The findings revealed that quality EmOC is a welcoming, life-saving timely care given in a clean environment with humility, respect, equal treatment and encouragement. It is care that is safe for the client, technically sound, responsive and meets clients’ needs and expectations. Accessibility of life saving care at all time and collaborative and coordinated care created good experiences for the clients. The causes of clients’ disappointment with the provision of EmOC were higher expectations from female providers, underestimation by providers, non responsive providers, and ethical misconduct by providers such as mocking, insulting, yelling, advantage taking providers, undelivered promises by providers, expectation with place of delivery, expectation with newborn care and a limited number of health workers attending delivery. Discrimination, high cost of care and asking client to buy drugs and supplies and referrals from centres, are some of the barriers on r the use of EmOC at public health facilities. The provision of EmOC is constrained by overloaded staffs, shortage of space to accommodate clients and inadequate number of beds. In conclusion, clients have expectations and experiences of provision of EmOC that influence their future decision to seek care. Finally, a client centred guideline for the provision of client centred EmOC provision was developed. / Health Studies / D. Litt. et Phil. (Health Studies)

CAPES / As unidades hospitalares compõem grande parte do setor de serviços. Desta forma, esses locais são fortemente influenciados pela lógica de acumulação capitalista, pela tecnologia e pelas formas de organização do trabalho, em especial as organizações privadas. Com o movimento de reorganização produtiva e incorporação de tecnologias, são diversas as mudanças no processo de trabalho e, por conseguinte, nas atividades dos profissionais médicos. No decorrer da elaboração desse trabalho foram identificados elementos acerca da banalização do mal. Essa banalização e resignação dos profissionais frente a violência são desencadeadas pela adoção de estratégias coletivas de defesa. Sendo assim, esse trabalho tem por objetivo geral analisar como ocorre a racionalização das condições de trabalho por parte de ginecologistas obstetras e pediatras atuantes na urgência e emergência de hospitais públicos e privados de Curitiba e Região Metropolitana. Como procedimentos metodológicos, utilizou-se a abordagem de métodos mistos. A naturalização da violência, do sofrimento na qual os profissionais são submetidos, estão aliadas ao controle político-ideológico, controle burocrático, o imaginário construído acerca dos hospitais e as estratégias coletivas de defesa. Portanto, é possível compreender que as condições de trabalho de ginecologistas obstetras e pediatras na urgência e emergência são racionalizadas. Quando a injustiça social é naturalizada não são possíveis estratégias políticas de mudanças. Por isso, o primeiro passo é a tomada de consciência, é preciso desvelar a realidade, compreender os fenômenos em seu cerne e descartar superficialidades. É também necessário que as ações e as manifestações de indignação estejam aliadas a ações políticas com vistas a transformações. / Hospitals are a big part of the service sector. Thus, such institutions are highly influenced by the logic of the capitalist accumulation, technology and forms of labor organization, especially by private organizations. Starting with the restructuring process motion and incorporation of technologies, many changes in the working process occur, therefore, the activities of medical professionals as well. During the preparation of this research items regarding the banalization of evil were identified. This banalization and resignation of the professionals face to violence are caused by the adoption of collective defense strategies. Therefore, this research aims to analyze how the rationalization of working conditions by gynecologists obstetricians and pediatricians working in the emergency rooms of public and private hospitals in Curitiba and metropolitan region occurs. An approach of mixed methods was used as methodological procedures. The naturalization of violence, the suffering which professionals are submitted to, are combined with the political and ideological control, bureaucratic control, the imaginary built about hospitals and collective defense strategies. It is therefore possible to understand that labor conditions of gynecologists obstetricians and pediatricians in emergency rooms are rationalized. When social injustice is naturalized, political strategies for changes are not possible. For this reason, the first step is to gather awareness, there is a need to unveil the reality, to understand the phenomena at its core and discard superficialities. It is also necessary that the actions and expressions of indignation to come hand in hand with political actions in order to change to happen.

The contribution of Emergency Obstetric Care (EmOC) in reducing maternal mortality in Ethiopia is very minimal as evidenced by poor provision and low utilization of EmOC. Client centred EmOC provision improves the provision and utilization of EmOC; leading to the treatment of the majority of obstetric complications which are the main causes of maternal mortality. This study describes clients’ views and perspectives concerning the quality of EmOC provision in Ethiopian public health facilities. An explorative and descriptive phenomenological qualitative study design was used in the study in order to explore and describe the lived experiences of clients with EmOC services. Key informant interviews with women who had direct obstetric complications and received EmOC at three public health facilities in Addis Ababa generated rich data on their lived experiences. Content analysis was used to analyze the data as it complies with the phenomenological data analysis and Atlas ti version 6.2 qualitative data analysis software was employed. The findings revealed that quality EmOC is a welcoming, life-saving timely care given in a clean environment with humility, respect, equal treatment and encouragement. It is care that is safe for the client, technically sound, responsive and meets clients’ needs and expectations. Accessibility of life saving care at all time and collaborative and coordinated care created good experiences for the clients. The causes of clients’ disappointment with the provision of EmOC were higher expectations from female providers, underestimation by providers, non responsive providers, and ethical misconduct by providers such as mocking, insulting, yelling, advantage taking providers, undelivered promises by providers, expectation with place of delivery, expectation with newborn care and a limited number of health workers attending delivery. Discrimination, high cost of care and asking client to buy drugs and supplies and referrals from centres, are some of the barriers on r the use of EmOC at public health facilities. The provision of EmOC is constrained by overloaded staffs, shortage of space to accommodate clients and inadequate number of beds. In conclusion, clients have expectations and experiences of provision of EmOC that influence their future decision to seek care. Finally, a client centred guideline for the provision of client centred EmOC provision was developed. / Health Studies / D. Litt. et Phil. (Health Studies)