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While the concept of regional organization (regionalization) of perinatal care aimed at reducing perinatal mortality has remained at the agenda of developed countries since 1970&rsquo / s, Turkey is one of the countries that does not have such a system yet. In this study, a three-level hierarchical location-allocation model is developed for the regionalization of perinatal care in an attempt to have a better distribution of maternal and perinatal health care services in Turkey. Since the mathematical model developed is difficult to solve in a reasonable time, we propose three heuristic approaches: top-down, modified top-down and Lagrangean relaxation based heuristics. These heuristics are computationally tested on a set of problem instances for networks ranging from 10 to 737 vertices. A significant result is that Lagrangean relaxation based heuristic outperforms the other two heuristics in terms of solution quality. In most of the test problems, the modified top-down heuristic outperforms the top-down heuristic in terms of solution quality. Using the proposed approaches, we solve a real life problem corresponding to the Eastern and South Eastern Anatolian Regions (the East Region) of Turkey.

<p>Medicinsk abort innebär avbrytande av graviditet på farmakologisk väg, det kan utföras tilloch med nionde graviditetsveckan. Hemabort innebär att kvinnor slutför en medicinsk abort isitt hem, det har varit tillåtet i Sverige sedan 2004. Tidigare studier visar att kvinnor uppleverhemabort som mer naturligt än abort utförd på sjukhus. Stöd kan ses utifrån fyra dimensioner;informativt, instrumentellt, emotionellt och bekräftade. Syftet med studien var att beskrivakvinnors upplevelse av stöd från barnmorskor i samband med medicinsk hemabort. Metodensom använts är kvalitativ innehållsanalys utifrån en induktiv ansats. Datainsamlingen har skettgenom en enkät med öppna frågor. Sex kvinnor valde att delta i studien. Resultatet indelades isex kategorier och ett tema. Resultatet visar att även fast kvinnorna upplever utsatthet, är denöjda med det stöd de erbjuds. Kvinnorna känner sig väl informerade, delaktiga och trygga;de uppskattar telefonsamtalet från barnmorska under abortdagen samt att de kan nå sjukhusetdygnet runt.</p> / <p>Medical abortion means termination of pregnancy in a pharmacological way, it can beperformed until the ninth week of pregnancy. Abortion at home means that women completea medical abortion in their homes, it has been allowed in Sweden since 2004. Previous studiesillustrate that women experience abortion at home as more natural than abortion performed athospital. Support can be seen from four different dimensions; informational, instrumental,emotional and appraisal. The aim of the study was to describe women’s experiences ofsupport from midwives in connection to induced medical abortion at home. The method usedis qualitative content analysis with an inductive approach. The collecting of data has beenmade through a questionnaire with open questions. Six women chose to participate in thestudy. The result was divided into six categories and one theme. The result shows that eventhough the women feel vulnerable, they are satisfied with the support they are offered. Thewomen feel that they are well informed, involved and safe; they appreciate the call from themidwife during the day of the abortion, also that the hospital can be reached day and night.</p>

Medicinsk abort innebär avbrytande av graviditet på farmakologisk väg, det kan utföras tilloch med nionde graviditetsveckan. Hemabort innebär att kvinnor slutför en medicinsk abort isitt hem, det har varit tillåtet i Sverige sedan 2004. Tidigare studier visar att kvinnor uppleverhemabort som mer naturligt än abort utförd på sjukhus. Stöd kan ses utifrån fyra dimensioner;informativt, instrumentellt, emotionellt och bekräftade. Syftet med studien var att beskrivakvinnors upplevelse av stöd från barnmorskor i samband med medicinsk hemabort. Metodensom använts är kvalitativ innehållsanalys utifrån en induktiv ansats. Datainsamlingen har skettgenom en enkät med öppna frågor. Sex kvinnor valde att delta i studien. Resultatet indelades isex kategorier och ett tema. Resultatet visar att även fast kvinnorna upplever utsatthet, är denöjda med det stöd de erbjuds. Kvinnorna känner sig väl informerade, delaktiga och trygga;de uppskattar telefonsamtalet från barnmorska under abortdagen samt att de kan nå sjukhusetdygnet runt. / Medical abortion means termination of pregnancy in a pharmacological way, it can beperformed until the ninth week of pregnancy. Abortion at home means that women completea medical abortion in their homes, it has been allowed in Sweden since 2004. Previous studiesillustrate that women experience abortion at home as more natural than abortion performed athospital. Support can be seen from four different dimensions; informational, instrumental,emotional and appraisal. The aim of the study was to describe women’s experiences ofsupport from midwives in connection to induced medical abortion at home. The method usedis qualitative content analysis with an inductive approach. The collecting of data has beenmade through a questionnaire with open questions. Six women chose to participate in thestudy. The result was divided into six categories and one theme. The result shows that eventhough the women feel vulnerable, they are satisfied with the support they are offered. Thewomen feel that they are well informed, involved and safe; they appreciate the call from themidwife during the day of the abortion, also that the hospital can be reached day and night.

O parto e o nascimento são eventos de grande relevância. O atendimento especializado à mulher por ocasião do parto é fundamental para a redução da mortalidade materna e neonatal, porém muitas mulheres em países de baixa e média renda são assistidas fora das unidades de saúde, sem ajuda especializada. Nesta pesquisa, avaliamos o impacto da regionalização do acesso aos serviços de saúde responsáveis pela atenção ao parto e ao nascimento enquanto política pública instituída no Rio Grande do Sul em 2004. Identificamos os óbitos infantis evitáveis, relacionados a partos ocorridos em hospitais de pequeno porte, em especial aqueles com ocorrência de nascimentos inferior a 104 partos anuais e localizados em pequenos municípios. A realocação dos partos desses estabelecimentos para outros de maior ocorrência foi definida como uma das ações para a redução da mortalidade infantil. Os nascimentos e óbitos infantis registrados em 2004 foram selecionados por município de ocorrência hospitalar do nascimento e distribuídos em cinco estratos de parto anual: 1 a < 104; 104 a < 208; 208 a < 365; 365 e +; e zero. Analisamos os coeficientes de mortalidade neonatal precoce, neonatal tardia, infantil tardia e infantil por estrato de parto anual em 2004 e em 2013, 10 anos após a instituição da regionalização. Os municípios do menor estrato de ocorrência de nascimentos foram considerados prioritários nesse processo. Analisamos, também, diversas variáveis relacionadas à mãe, ao parto e nascimento, ao recém-nascido, ao nível de desenvolvimento municipal e sua relevância em relação à regionalização. Para cada óbito ocorrido no primeiro ano de vida em 2004 e em 2013, identificamos o município de ocorrência do nascimento da criança falecida e calculamos os coeficientes de mortalidade por município de ocorrência do nascimento para cada estrato de parto. O período 2004 a 2013 apresentou redução dos coeficientes de mortalidade infantil em todos os componentes por faixa etária de ocorrência do óbito e por estrato de parto. No nível estadual, o coeficiente de mortalidade neonatal precoce por município de residência da mãe caiu de 7,20 para 4,93, o de mortalidade neonatal tardia de 2,87 para 2,22, o de mortalidade infantil tardia de 5,09 para 3,46 e o de mortalidade infantil de 15,16 para 10,61. Houve uma redução estatisticamente significativa dos coeficientes de mortalidade neonatal precoce, mortalidade infantil tardia e mortalidade infantil no conjunto dos 55 municípios regionalizados e dos coeficientes de mortalidade neonatal precoce, mortalidade neonatal tardia, mortalidade infantil tardia e mortalidade infantil no conjunto de 214 municípios referência de parto à gestante de risco habitual. Em conclusão, a estratégia foi eficiente para a redução da mortalidade infantil em nível estadual, tanto nos 55 municípios com parto regionalizado quanto nos 58 municípios que receberam gestantes desses municípios com parto regionalizado, assim como nos demais 156 municípios referência de parto à gestante de risco habitual que não receberam gestantes desses municípios com parto regionalizado. / Delivery and childbirth are very important events. However, many women in low- and middle-income countries receive care outside health facilities, without specialized assistance. In this study, we evaluated the impact of regionalization of access to health services involving delivery and birth care as a public policy implemented in Rio Grande do Sul in 2004. We identified preventable neonatal deaths related to births occurring in small hospitals, especially those with a rate of less than 104 births per year and located in small municipalities. Relocation of deliveries from these hospitals to other facilities with higher birth rates was defined as an action to reduce infant mortality. All births and infant deaths recorded in 2004 were selected according to the municipality where the hospital birth occurred and distributed in five strata of annual childbirth: 1 to < 104; 104 to < 208; 208 to < 365; 365 and +; and zero. We analyzed early neonatal, late neonatal, late infant and infant mortality rates by annual childbirth stratum in 2004 and in 2013, 10 years after the implementation of regionalization. Municipalities within the lowest stratum of hospital births were considered a priority in the regionalization process. We also analyzed several variables related to the mother, the birth, the neonate, the level of municipal development, and its relevance in relation to regionalization. For each death in the first year of life occurring in 2004 and in 2013, we identified the municipality where the deceased child was born and calculated mortality rates by municipality of hospital birth for each childbirth stratum. The 2004-2013 period showed a reduction in mortality rates in all components per age at death and per childbirth stratum. At the state level, early neonatal mortality rate per mother’s place of residence dropped from 7.20 to 4.93, late neonatal mortality rate from 2.87 to 2,22, late infant mortality rate from 5.09 to 3.46, and infant mortality rate from 15.16 to 10.61. There was a statistically significant reduction in early neonatal mortality, late infant mortality and infant mortality rates in the group of 55 regionalized municipalities and in early neonatal mortality, late neonatal mortality, late infant mortality and infant mortality rates in the group of 214 municipalities serving as referral centers for normal-risk delivery. In conclusion, the strategy was effective in reducing infant mortality at the state level, both in the 55 municipalities with regionalized delivery care and in the 58 municipalities that received pregnant women from these municipalities, as well as in the remaining 156 municipalities identified as referral centers for normal-risk deliveries that did not receive pregnant women from the municipalities with regionalized delivery care.

O parto e o nascimento são eventos de grande relevância. O atendimento especializado à mulher por ocasião do parto é fundamental para a redução da mortalidade materna e neonatal, porém muitas mulheres em países de baixa e média renda são assistidas fora das unidades de saúde, sem ajuda especializada. Nesta pesquisa, avaliamos o impacto da regionalização do acesso aos serviços de saúde responsáveis pela atenção ao parto e ao nascimento enquanto política pública instituída no Rio Grande do Sul em 2004. Identificamos os óbitos infantis evitáveis, relacionados a partos ocorridos em hospitais de pequeno porte, em especial aqueles com ocorrência de nascimentos inferior a 104 partos anuais e localizados em pequenos municípios. A realocação dos partos desses estabelecimentos para outros de maior ocorrência foi definida como uma das ações para a redução da mortalidade infantil. Os nascimentos e óbitos infantis registrados em 2004 foram selecionados por município de ocorrência hospitalar do nascimento e distribuídos em cinco estratos de parto anual: 1 a < 104; 104 a < 208; 208 a < 365; 365 e +; e zero. Analisamos os coeficientes de mortalidade neonatal precoce, neonatal tardia, infantil tardia e infantil por estrato de parto anual em 2004 e em 2013, 10 anos após a instituição da regionalização. Os municípios do menor estrato de ocorrência de nascimentos foram considerados prioritários nesse processo. Analisamos, também, diversas variáveis relacionadas à mãe, ao parto e nascimento, ao recém-nascido, ao nível de desenvolvimento municipal e sua relevância em relação à regionalização. Para cada óbito ocorrido no primeiro ano de vida em 2004 e em 2013, identificamos o município de ocorrência do nascimento da criança falecida e calculamos os coeficientes de mortalidade por município de ocorrência do nascimento para cada estrato de parto. O período 2004 a 2013 apresentou redução dos coeficientes de mortalidade infantil em todos os componentes por faixa etária de ocorrência do óbito e por estrato de parto. No nível estadual, o coeficiente de mortalidade neonatal precoce por município de residência da mãe caiu de 7,20 para 4,93, o de mortalidade neonatal tardia de 2,87 para 2,22, o de mortalidade infantil tardia de 5,09 para 3,46 e o de mortalidade infantil de 15,16 para 10,61. Houve uma redução estatisticamente significativa dos coeficientes de mortalidade neonatal precoce, mortalidade infantil tardia e mortalidade infantil no conjunto dos 55 municípios regionalizados e dos coeficientes de mortalidade neonatal precoce, mortalidade neonatal tardia, mortalidade infantil tardia e mortalidade infantil no conjunto de 214 municípios referência de parto à gestante de risco habitual. Em conclusão, a estratégia foi eficiente para a redução da mortalidade infantil em nível estadual, tanto nos 55 municípios com parto regionalizado quanto nos 58 municípios que receberam gestantes desses municípios com parto regionalizado, assim como nos demais 156 municípios referência de parto à gestante de risco habitual que não receberam gestantes desses municípios com parto regionalizado. / Delivery and childbirth are very important events. However, many women in low- and middle-income countries receive care outside health facilities, without specialized assistance. In this study, we evaluated the impact of regionalization of access to health services involving delivery and birth care as a public policy implemented in Rio Grande do Sul in 2004. We identified preventable neonatal deaths related to births occurring in small hospitals, especially those with a rate of less than 104 births per year and located in small municipalities. Relocation of deliveries from these hospitals to other facilities with higher birth rates was defined as an action to reduce infant mortality. All births and infant deaths recorded in 2004 were selected according to the municipality where the hospital birth occurred and distributed in five strata of annual childbirth: 1 to < 104; 104 to < 208; 208 to < 365; 365 and +; and zero. We analyzed early neonatal, late neonatal, late infant and infant mortality rates by annual childbirth stratum in 2004 and in 2013, 10 years after the implementation of regionalization. Municipalities within the lowest stratum of hospital births were considered a priority in the regionalization process. We also analyzed several variables related to the mother, the birth, the neonate, the level of municipal development, and its relevance in relation to regionalization. For each death in the first year of life occurring in 2004 and in 2013, we identified the municipality where the deceased child was born and calculated mortality rates by municipality of hospital birth for each childbirth stratum. The 2004-2013 period showed a reduction in mortality rates in all components per age at death and per childbirth stratum. At the state level, early neonatal mortality rate per mother’s place of residence dropped from 7.20 to 4.93, late neonatal mortality rate from 2.87 to 2,22, late infant mortality rate from 5.09 to 3.46, and infant mortality rate from 15.16 to 10.61. There was a statistically significant reduction in early neonatal mortality, late infant mortality and infant mortality rates in the group of 55 regionalized municipalities and in early neonatal mortality, late neonatal mortality, late infant mortality and infant mortality rates in the group of 214 municipalities serving as referral centers for normal-risk delivery. In conclusion, the strategy was effective in reducing infant mortality at the state level, both in the 55 municipalities with regionalized delivery care and in the 58 municipalities that received pregnant women from these municipalities, as well as in the remaining 156 municipalities identified as referral centers for normal-risk deliveries that did not receive pregnant women from the municipalities with regionalized delivery care.

This thesis deals with the topic of providing perinatal care from the patient's point of view. The aim of the thesis is to use national legislation and decisions of Czech and international courts to determine under what conditions a woman has the right to decide on the provided health services. From the legal point of view the area of perinatal care brings many questions where it is not easy, also with regard to the ethical aspect of things, to find an answer. During the pregnancy and childbirth, there are situations in which two constitutionally guaranteed rights conflict and with regard to the health services provided, it is necessary to evaluate the situation individually. In the introductory chapters the thesis summarizes the legal regulation including the constitutional law of the provision of health services. Emphasis is placed on the rights of the patient, especially the possibility to decide on the provided health care in different situations. A separate chapter is devoted to the institute of previously expressed wish and its application to the period of delivery. In the context of postnatal care, the legal regulation of parents' decisions about the health services provided to their child is mentioned. The field of healthcare law requires the introduction of legislation into the context of...

À l'heure actuelle, les résultats périnataux en France demeurent parmi les moins satisfaisants en Europe malgré une très forte médicalisation. Les autorités de santé affirment reconnaître l'influence de la prise en charge et de l'accompagnement pendant la grossesse, l'accouchement et la période néonatale sur l'état de santé de la mère et de l'enfant mais l'offre de soins peine à s'élargir. Contrairement à ce que prévoient les lois concernant le libre choix du praticien en France, les parturientes ne sont pas à même de choisir le professionnel de santé qui les accompagnera lors de leur accouchement. De même, les sages-femmes, contrairement à ce qu'impose leur code de déontologie, ne sont pas en mesure de garantir à leurs patientes ni les conditions, ni le lieu de leur accouchement. De surcroît, peu d'entre elles exercent leur profession de façon autonome tout en pratiquant le plein exercice de leur fonction. En centrant cette recherche anthropologique sur l'expérience des femmes et des sages-femmes dans leurs relations autour de la naissance et de l'accouchement, l'objectif de cette étude qualitative est de faire la lumière sur les tenants et les aboutissants de l'uniformisation de l'offre de soins. Dans un premier temps sont abordés les différents types d'accompagnement proposés aux femmes aujourd'hui ainsi que la place qu'y occupent les sages-femmes. Dans un second temps, l'étude de l'accompagnement global permet l'examen de la prise en charge des patientes et de ses liens de causalité avec les relations interprofessionnelles. Ainsi sont révélés les impacts de cette pratique sur le soutien à la parentalité et la nécessité d'une diversification de l'offre de soins. / Currently, the perinatal results in France remain among the least satisfactory in Europe in spite of a very strong medicalization. However, health authorities acknowledge the influence of maternity care during pregnancy, childbirth and neonatal period on the state of health of the mother and the child but health services hardly increase. Contrary to what French law says on free choice of practitioner, parturient women cannot choose the health professional who will assist them during labor. Likewise, midwives cannot guarantee their patients the place and conditions of childbirth, contrary to their code of ethics. In addition, few of them have the opportunity to work in an independent way and at the same time fully practice their profession. By focusing this anthropological research on women's and midwives' experience in their relationships around childbirth, the aims of this qualitative study are to clarify the ins and outs of the standardization of health services. Initially, the various types of care provided to women today and the place granted to midwives are discussed. Secondly, possible causal links between interprofessional relations and maternity care are searched for through the study of comprehensive care. So are revealed the impacts of a close and trusting relationship in supporting parenthood and of a diversification of health services.

Orientadores: Maria de Lurdes Zanolli, Roberto Teixeira Mendes / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T12:51:00Z (GMT). No. of bitstreams: 1 Queiroz_PatriciaHelenaBreno_D.pdf: 2651235 bytes, checksum: 6f5fb1ee7f755286f20c3b8766b25740 (MD5) Previous issue date: 2014 / Resumo: Este trabalho teve como objetivo geral compreender a influência das avós de bebês, filhos de mães adolescentes, no exercício e duração do aleitamento materno nos primeiros seis meses de vida; buscando entender na perspectiva das avós e das mães adolescentes o papel que as avós desempenham na gestação e maternidade adolescente e as concepções destas mulheres acerca do estabelecer e vivenciar a amamentação. A pesquisa seguiu um delineamento de caráter exploratório e natureza qualitativa. As adolescentes e as avós dos bebês foram convidadas a participar da pesquisa, a partir do último trimestre de gestação e conceder mais quatro entrevistas orientadas por roteiro semiestruturado, no puerpério imediato, aos 30, 120 e 180 dias após o nascimento, entre 14 de fevereiro de 2012 e 14 de maio de 2013. O material produzido após a leitura das transcrições das entrevistas foi agrupado em categorias e subcategorias e interpretado utilizando-se da Análise de Conteúdo Temático. Participaram do estudo 25 duplas de adolescentes e suas mães ou sogras. Quando perguntadas durante o pré-natal se sabiam o que era aleitamento materno (AM), 05 adolescentes reconheceram o conceito e 13 só o fizeram após uma explicação. Durante a visita no pós-parto imediato, 22 "recém-mães" informaram que não foram orientadas sobre AM durante o pré-natal, mas todas indicaram a equipe de enfermagem do Alojamento Conjunto do hospital, como responsável pelas orientações sobre amamentação. Na visita de 30 dias, 15 jovens referiram terem frequentado o ambulatório de AM no puerpério mediato, o que foi considerado importante para adequar a técnica de amamentação; duas relataram não terem continuado a amamentação de seus bebês quando em suas casas; quatro não completaram 30 dias de AM e substituíram por fórmulas introduzidas sob a recomendação de profissionais de saúde (farmacêutico, enfermeiro, pediatra). Dez de 19 de adolescentes que mantiveram o AM até o quarto mês foram orientadas pelo pediatra para a introdução de alimentos complementares. Somente nove bebês foram amamentados exclusivamente por seis meses. As mães e sogras atuam na retaguarda porque precisam retornar às suas atividades cotidianas e as adolescentes assumem o cuidado do bebê e muitas vezes, o trabalho doméstico. Neste contexto, os papéis de mãe e avó são definidos e a avós respeitam as escolhas de suas filhas. Intervenções dirigidas tanto para as adolescentes quanto para as avós, durante o período perinatal podem ter um efeito prolongador na amamentação, principalmente em famílias de mulheres-avós trabalhadoras que vão além do papel de "mãe de família" e contribuem para a subsistência desta / Abstract: This study aimed to understand the influence of grandparents of babies, children of adolescent mothers, exercise and duration of breastfeeding in the first six months of life; seeking to understand the perspective of grandparents and teenage mothers the role that grandparents play in pregnancy and teen motherhood and the conceptions of these women about the experience and establish breastfeeding. The research followed an exploration of character design and qualitative nature. The teenagers and grandmothers invited to participate in the study, from the last trimester of pregnancy and give four interviews guided by semi-structured, postpartum, 30, 120 and 180 days after birth, between February 14 2012 and May 14, 2013. The research design followed an exploratory and qualitative nature. The teenagers and grandmothers invited to participate in the research, from the last trimester of pregnancy and grant four semi-structured interviews guided by, postpartum, 30, 120 and 180 days after birth, between February 14 2012 and May 14, 2013. The material produced after reading the transcripts of the interviews, clustered into categories and subcategories and interpreted using the Thematic Content Analysis. The study included 25 pairs of adolescents and their mothers or mothers in law. When asked during the prenatal whether they knew what breastfeeding (BF) was, 05 adolescents recognized the concept and only 13 did so after an explanation. During the visit in the immediate postpartum period, 22 "new mothers" reported that were not oriented on BF during the prenatal, but all indicated the nursing staff of the hospital rooming, as responsible for the hospital on the guidelines breastfeeding. In 30-day visit, 15 young people reported having attended the outpatient clinic mediate the puerperium, which was considered important to adequate breastfeeding technique; two reported not have continued breastfeeding their babies while in their homes; four did not complete 30 days of BF and replaced by formulas introduced on the recommendation of health professionals (pharmacist, nurse, pediatrician). Of the19 adolescent, 10 maintained their AM until the fourth month, told by the pediatrician for the introduction of complementary foods. Only nine babies were exclusively breastfed for six months. Mothers and mothers in law act in rearward backwards because they need to return to their daily activities and teenagers take care of the baby and often the housework. The roles of mother and grandmother defined and grandparents respected the choices of their daughters. Interventions aimed both to teens and to grandparents during the perinatal period can have an effect on prolonging breastfeeding, especially in families of working women-grandmothers who go beyond the role of "mother of the family" and contribute to the subsistence of this / Doutorado / Saude da Criança e do Adolescente / Doutora em Ciências

Background: South Africa aims to end all preventable deaths of children under the age of five as part of their commitment to the Sustainable Development Goals. More than half of these mortalities occur in the neonatal period with perinatal asphyxia as one of the leading causes. This study investigated and identified the characteristics of perinatal asphyxia and its contributing factors at a district hospital in Cape Town. Methods: A retrospective descriptive case series was performed and included all suspected cases of perinatal asphyxia referred from Mitchells Plain District Hospital (MPH)) to a specialised centre in the years 2016-2018. A data collection tool was used to extract information. Data was processed with SPSS to produce descriptive statistics and to investigate associations between variables using the Chi-square tests. Results: The study included 29 cases of suspected perinatal asphyxia. Ten (34.5%) had abnormal amplitude Electroencephalograms (aEEG's) indicative of Hypoxic Ischaemic Encephalopathy (HIE) and four (13.8%) demised before day seven of life. Non-operative deliveries (p=0.005), lack of a doctor at the time of delivery (p=0.004) and neonatal chest compressions (p=0.044) were associated with abnormal aEEG's. Babies with Thompson score of equal to or more than 12 (p=0.006), neonatal seizures (p=0.036) and delayed arrival at referral hospital (p=0.005) were associated with abnormal aEEG findings. Mortality was associated with Thompson score ≥12 (p=0.007) and the need for neonatal intubation at delivery (p=0.016). Conclusions: Significant reversable factors were identified in the peri-and postpartum periods. More capacitated staff would have the greatest impact on outcomes. The profile of HIE is exceedingly complex and challenges the resources and services of district level of care. Therefore, these factors should be targeted for future development and investment to improve outcomes from district hospitals.