A sharp increase in caesarean section (CS) rates at the Muhimbili National Referral Hospital (MNH) – a tertiary referral hospital in Tanzania – by 50% in 2000–2011, was associated with concomitant increase in maternal complications and deaths and inconsistent improvement in newborn outcomes. The aims of this thesis were to explore care providers’ in-depth perspective of the reasons for these high rates of CS, and to evaluate and improve standards of care for the most common indica-tions of CS, obstructed labour and fetal distress, which are also major causes of adverse maternal and neonatal outcomes. This thesis reports an investigation performed at MNH, Tanzania. For Paper I, qualitative methods were employed and demonstrated how care providers dismissed their responsibility for the rising CS rate; and, instead, projected the causes onto factors beyond their control. Additionally, dysfunctinal teamwork, transparency, and previous poorly conducted clinical audits led to fear of blame among care providers in cases of poor outcome that subsequently encougared defensive practise by assigning unnecessary CS. Papers II and III evaluated stand-ards of care using a criteria-based audit (CBA) of obstructed labour and fetal dis-tress. After implementing audit-feedback recommendations, the standards of diag-nosis of fetal distress improved by 16% and obstructed labour by 7%. Similarly, the standards of management preceding CS improved tenfold for fetal distress and doubled for obstructed labour. The impact of the CBA process was evaluated by comparing the maternal and perinatal outcomes categorized into Robson groups (Paper IV) of all deliveries occurring before and after the audit process (n=27,960). After the CBA process, there was a 50% risk reduction of severe perinatal morbidi-ty/mortality for patients with obstructed labour. The overall CS rates increased by 10%, and this was attributed to an increase in the CS rate among breech, term preg-nancies (Robson group 6), and preterm pregnancies (Robson group 10) that specifi-cally had reduced risk of poor perinatal outcome. The overall neonatal distress rates were also reduced by 20%, and this was attributed to a decrease in the neonatal distress rate among low-risk, term pregnancies (Robson group 3). Importantly, the increased rates of poor perinatal outcomes were associated with referred patients that had higher risk of neonatal distress and PMR than non–referred patients, after CBA process.  In conclusion, the studies managed to educate the care providers to take on their roles as decision-makers and medical experts to minimize unnecessary CS, using the available resources. Care providers’ commitment to achieve the best practice should be sustained and effort for stepwise upgrading quality of obstetric care should be supported by the hospital management from the primary to tertiary referral level.

Masters of Science - Msc (Physiotherapy) / Post-operative physiotherapy plays a vital role in the management of patients with incontinence in order to optimise the outcome of obstetric fistula surgery. Women who suffer residual urinary incontinence continue to experience shame, social isolation and institutional rejection. Incontinence continues to impair them leading to lower levels of role participation and restriction in most activities. Gynocare Fistula Center, Eldoret, receives a number of referrals for women with obstetric fistula requiring surgical and physiotherapy care. Many studies have focused on the determinants of surgical outcomes and social reintegration but none have focused on woman's perceptions and experiences with postoperative physiotherapy. While continence is not always achieved immediately after surgery, this study was designed to explore women's perceptions and experience of postoperative physiotherapy management at an obstetric fistula center in Eldoret,Kenya. Participants were then asked about their experiences and related perceptions and perceived challenges regarding the physiotherapy service following discharge from the Center. An explorative qualitative method was used to explore the women's perceptions and experiences of the post-operative physiotherapy management, as well as their perceived challenges regarding access to physiotherapy post discharge.

Obstructed labour contributes significantly to the morbidity and mortality among both mothers and babies in Ethiopia nationwide, and also in the West-Wollega region where this study was conducted. The researcher used a retrospective hospital based review of maternity files to quantify the problem of obstructed labour in the selected hospital. The findings revealed that maternal and perinatal mortality due to obstructed labour amounted to 1.4% and 7.5% respectively. Most of these complications could be prevented by proper antenatal care and careful attentive monitoring during delivery with proper use of the partogram which will indicate the occurrence of complications in good time when successful and life saving interventions are still available. The findings clearly show that poor documentation in general and very sporadic usage of the partogram in particular contributes significantly to the complications for mother and child. Re-introduction of proper documentation and careful use of the partogram are advocated / Health Studies / M.A. (Public Health)

Obstructed labour contributes significantly to the morbidity and mortality among both mothers and babies in Ethiopia nationwide, and also in the West-Wollega region where this study was conducted. The researcher used a retrospective hospital based review of maternity files to quantify the problem of obstructed labour in the selected hospital. The findings revealed that maternal and perinatal mortality due to obstructed labour amounted to 1.4% and 7.5% respectively. Most of these complications could be prevented by proper antenatal care and careful attentive monitoring during delivery with proper use of the partogram which will indicate the occurrence of complications in good time when successful and life saving interventions are still available. The findings clearly show that poor documentation in general and very sporadic usage of the partogram in particular contributes significantly to the complications for mother and child. Re-introduction of proper documentation and careful use of the partogram are advocated / Health Studies / M.A. (Public Health)