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