Interpretation
In November 2017, where the number of deliveries was below
pre-dimensioned capacity, the study disclosed a doubling of the
caesarean section rate and a simultaneous increase in labour inductions,
but no other differences in quality of intrapartum care and birth
outcomes. This was surprising, but in fact the ability to provide good
quality CEmONC services despite a high and ever-increasing caseload, is
similar to data from an MSF run hospital in a conflict-affected province
of Afghanistan. 19 When conducting our study, the Taiz
Houbane MCH Hospital had already worked above the pre-dimensioned
capacity during the previous three months, and both studies demonstrate
the impressive resilience of health workers to cope with extreme
workloads. Importantly, our study did not assess caring support and
working conditions for the staff, which might have deteriorated if the
high birth loads had persisted for a longer time.19 As
reported from busy maternity units in sub-Saharan Africa, workload far
beyond capacity may lead to demotivation, burnout and impaired
performance among providers.20-23 On the other hand,
the working conditions at the MSF run hospitals may, even when
congested, be of higher quality than in governmental hospitals within
fragile, resource constrained healthcare systems; regarding leadership,
accountability, teamwork, guidance and transparency. Furthermore,
compared to busy low-resource hospitals in East Africa with workloads
similar to the high-volume month, the quality of care provided at these
MSF run hospitals is much higher, and the intra-hospital stillbirth
rates of 2.3-9.7 much lower.21,24-28 This may in
itself be a positive driver among staff to keep providing quality care
even when working 50% above capacity. Another explanation could be that
the birth-attendant-to-labouring-women ratio at these MSF run hospitals
remained above an unknown critical threshold for deterioration of
quality in care.
Though the quality of care at the Taiz Houbane MCH Hospital may be
encouraging, it was not optimal. Among vaginal births, 18% took place
without even one correct plot on the partograph, in a quarter of cases
foetal heart monitoring during first stage of labour occurred less
frequently than every hour, and 29% of women did not have their blood
pressure measured at least every four hours. Moreover, a concerning
issue is the increase in labour inductions and caesarean sections in the
low-volume month. Among caesarean sections due to prolonged labour, 30%
were carried out in women who did not have at least one correct plot on
the partograph, and in 43.4% of these cases augmentation with oxytocin
was not tried. Further studies are called for to assess this potential
over-medicalization. Notably, interim practice led by humanitarian aid
and provided by local health workers may become institutionalized into a
new standard practice, also after the conflict. This was for instance
seen at a Tanzanian district hospital hosting a refugee camp during the
Rwandan genocide. Here, the caesarean section rate doubled during this
period, and it never reduced again – but maternal and perinatal
outcomes did not improve and surgical complications increased.
Literature is scarce on quality of care in CEmONC facilities in
FCAS.9,19 In contrast to the low intrafacility
stillbirth rates, rates of stillbirths with intrauterine foetal death on
admission of 32.9 and 43.6 per 1000 total births are unacceptably high,
and similar to the Afghani MSF hospital (29 per 1000 total
births).19 Also, 24% of multiparous women in the
present study suffered from previous loss of a child. These findings
suggest severe substandard of health system performance at the
population level and large unmet need for services. Rates of facility
births in Yemen are traditionally low, with approximately 30% of women
giving birth in health facilities in 2013.3 Assuming
that women who opt for a facility birth are more likely to attend ANC,
the finding that less than half of women in the current study had
attended ANC becomes even more worrying, and likely reflects the
war-related reduction in service availability. In comparison, a pre-war
house-hold survey from Taiz Governorate reported that 66% of women
attended ANC at least once.3 Another symptom of the
limited health system, which is similarly reported from
conflict-affected regions of Pakistan,30 is the
problematic self-administration of intravenous oxytocin among Yemeni
women, which can lead to uterine hyperstimulation, foetal death, uterine
rupture and bleeding after birth.31