Editor's Comment

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It has been said many times that we know how to save the lives of women with obstetric complications. Techniques to prevent some complications and treat others have been subject to careful scrutiny, especially through the Cochrane collaboration. Why then, as more resources and personnel are allocated to achieving Millennium Development Goal 5, are women still dying from obstetric complications? The answer, of course, is far from simple; but one reason is that despite the existence of carefully developed, tested, reviewed, and re-reviewed protocols, they are often not followed. For example, a study by Miller et al. [1] examined maternal mortality in a hospital in the Dominican Republic and found that government-issued protocols were largely ignored. Two studies are reported in this issue of the Keystone section, one from Argentina and Uruguay [2] and another from China [3], which found low compliance with protocols. In the case of China, one reason is that much of the literature on protocols is not published in Chinese, and thus clinicians have inadequate information and, for the same reason, have limited capacity to seek more. The situation is by no means limited to obstetrics. One review learned that it took an average of 17years for an improved practice to make its way into common practice [4]. Surgical innovations may require less time for wide acceptance.

One current challenge for emergency obstetric care is to increase the uptake of knowledge of accepted clinical protocols into widespread clinical practice. There are many approaches to this, ranging from regular audits of case management to withholding accreditation for noncompliant treatment. Implementation science examines the effectiveness of different means of encouraging adherence to many kinds of protocols including clinical ones, and needs to be applied to emergency obstetric care.

The third paper in this issue describes a program to improve pre-service training in the area of postabortion care [5]. Clinicians have a tendency to practice as they were taught in medical/nursing school, and thus improving the quality of pre-service training is an important beginning. However, it is absolutely essential that experienced clinicians also continue to be aware of and to adopt newly accepted practice. National professional societies (of obstetricians, midwives, and nurses) could play an invaluable role in reviewing, accepting, circulating, teaching, and encouraging the adoption of best clinical practice.

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References 

1. Miller S, Cordero M, Coleman AL, Figueroa J, Brito-Anderson S, Dabagh R, et al. Quality of care in institutionalized deliveries: the paradox of the Dominican Republic. Int J Obstet Gynecol. 2003;82(1):89–103
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2. Karolinski A, Mazzoni A, Belizan JM, Althabe F, Bergel F, Buekens P. Lost opportunities for effective management of obstetric conditions to reduce maternal mortality and severe maternal morbidity in Argentina and Uruguay. Int J Obstet Gynecol. 2010;110(2):174–179
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3. Yu G, Barclay L. Availability and quality of emergency obstetric care in Shanxi Province, China. Int J Obstet Gynecol. 2010;110(2):180–184
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4. Westfall JM, Mold J, Fagnan L. Practice-based research – “Blue Highways” on the NIH roadmap. JAMA. 2007;297(4):403–406
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5. Akiode A, Fetters T, Daroda R, Okeke B, Oji E. An evaluation of a national intervention to improve postabortion care content of midwifery education in Nigeria. Int J Obstet Gynecol. 2010;110(2):185–189
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