According to the World Health Organization (WHO), the African continent recorded the highest maternal mortality ratios in the world  . Since the call of Nairobi in 1987 for maternal health, epidemiology of maternal mortality is fairly well known. The causes are grouped into 3 groups with direct causes, indirect causes and contributing factors summarized in three delays model; the third delay is the intra-hospital one      .
Since 2006, the Government of Burkina Faso has awarded a grant to obstetric and neonatal emergencies care (EmOC). The subsidy for the transportation of patients, hospital costs and emergency medicines was supposed to lessen the different delays in the care to pregnant women and newborns  . So a few years after the implementation of this new strategy, we intend to evaluate the intra-hospital delay in the management of patients within the first National and University referral hospital in Burkina Faso.
2. Patients and Methods
It has been a prospective cross-sectional study with descriptive and analytical aim in the obstetrics and gynecology department at the University Teaching Hospital Yalgado Ouédraogo of Ouagadougou. This department is the reference center for gynecological and obstetric emergencies of all public and private health facilities in the city of Ouagadougou. It has a capacity of one hundred and twelve (112) hospital beds.
The survey was conducted over a period of four (4) months from 1st May to 31 August 2015. Were included in the study all patients received in the Gynecological and obstetrical emergencies and their escorts who have accepted to participate in our investigation. The survey was conducted by non-participatory observation. Data were collected in two phases. The first phase from the admission records, clinical records, delivery records, operating protocols and neonatal resuscitation. The second phase was done by interview of the patient and or escort through an anonymous questionnaire sent to them. The study variables related to demographics, personal and family history, clinical examination of the data, the time of the treatment and prognosis of the mother and child. Was considered as support delay, any management made after the first fifteen minutes following the admission of the patient, according to WHO criteria    . Data were entered and analyzed using a PC equipped with the SPSS 16.0 software English version. The ethical consideration taken into consideration had been respect for anonymity and confidentiality. Patient consent had also been obtained.
During our study, we recorded 2627 admissions. Delays in the management involved 216 patients that to say 8.2% of admissions. In total 56.5% of patients were admitted between 6 a.m and 6 p.m and 43.5% between 18 hours and 6 hours.
3.2. Socio-Demographics Characteristics
The average age of patients was 26.6 ± 6.2 years with extremes ranging from 16 and 46 years. The age group 20 to 29 years was highest with 30% of patients.
・ Socio-professional status
Housewives accounted 65.3% of the sample, women in the informal sector accounted 17.5%.
・ Level of instruction
Patients with a primary level of study represented 50% of the sample, those with high school 25.9%, those without educational level 16.7% and the upper level 7.4%.
・ Marital status
Patients living in a conjugal relationship represented 55.1% of the sample, those cohabiting represented 38.8%, the unmarried represented 5.6% and widows represented 0.5%.
Nulliparous women represented 32.9% of the sample, 26.9% of primiparous, 35.1% of pauciparous, 4.1% of multiparous and 0.9% of high parity.
・ Provenance of patients
In total 81% of the patients were from the city of Ouagadougou and 19% of surrounding communities.
3.3. Clinical Aspects
・ Admission mode
Patients had been referred in 85.7% of cases, transferred from another department of the UTH-YO in 0.5% of cases. In 13.8% of cases, they had consulted directly at the UTH-YO by self-reference.
・ Mode of transport
In 63.9% of cases, they were admitted by ambulance, 15.7% in private car, motorcycle in 8.8%, 7.4% in a taxi.
・ Qualification of the health worker having referred the patients
The patients had been referred by a midwife in 59.7% of cases, by a physician in 39.8% of cases and by a nurse in 0.5% of cases.
・ Obstetric admission pattern
The distribution of patients according to the reason for admission was presented in Table 1.
3.4. Therapeutic Aspects
・ Waiting period between admission and installation on the examination table
The average waiting period to install a patient on the examination table was 10.9 ± 0.7 minutes with extremes of 1 and 57 minutes.
・ Waiting period between installation of the patient and the beginning of the clinical examination
The average waiting period between the installation of the patient and the beginning of the clinical examination was 4.5 ± 0.6 minutes with extremes of 1 and 45 minutes.
・ Waiting period between clinical and early first aid
Table 1. Distribution of patients according obstetric diagnosis (n = 187).
*others: 1 cases of detention of dead egg, 1 pelvic trauma cases, 1 cases of threatened miscarriage, 1 cases of uterine rupture and 1 cases of snakebite envenomation.
The average waiting period between the clinical examination of the patient and the beginning of first aid was 127.2 ± 13.6 minutes (2 h 7 min) with extremes of 2 minutes and 533 minutes (8 h 53 min).
・ Waiting period between arrival and start of first aid
The average waiting period between the arrival of a patient and the beginning of first aid was 142.7 ± 13.5 minutes (2:23 min) with extremes of 16 and 546 minutes (9:06 min).
・ Qualification the health worker having welcomed the patient
The patient was greeted by a trainee interned in 88.9% of cases by a midwife in 7.4% of cases, by a physician specializing in 3.7% of cases.
・ Qualification of the health worker having done clinical exam
The patient had been examined by a doctor specializing in 54.1% of cases by a trainee interned in 43.5% of cases and by a midwife in 2.4% of cases.
・ Qualification of the health worker who made the diagnosis
The diagnosis was made by a physician specializing in 93.5% of cases, by a medical student in 5.1% of cases and by a midwife in 1% of cases.
・ Qualification of the health worker having given how to behave
The practical course of action was given by a doctor specializing in 98.2% of cases by a medical student in 0.9% of cases and by a midwife in 0.9% of cases.
・ Qualification of the health worker who administered the first aid
The treatment was administered to the patient by a physician specializing in 75.5% of cases by a medical student in 19.4% of cases and by a midwife in 5.1% of cases.
3.5. The Delay in Care
・ Delay factors
The distribution of the factors behind the management was presented in Table 2.
・ Proposals for patients and their escorts
The distribution of proposals and patients escorts to solve the problem of delay in care has been shown in Table 3.
3.6. Prognostic Aspects
3.6.1. Maternal Prognosis
We noted complications in 29 patients (13.4%). These complications were anemia in 26 patients (12.1%); suppuration of the wound in 2 patients (0.1%).
We recorded 2 cases of maternal death or a lethality of 0.1%. The causes of these deaths were marked by post-partum hemorrhage in 1 case and HELLP syndrome in 1 case.
3.6.2. Neonatal and Fetal Prognosis
Table 2. Breakdown of factors behind the support.
Table 3. Distribution of proposals made by patients and companions (n = 117).
We recorded 20 stillbirths in a total of 145 births that to say a frequency of 13.8%.
・ Settings newborns
The mean birth weight was 2910 g with a range of 1800 g and 3250 g. The average head circumference was 33 cm and the average birth size was 49 cm.
・ Neonatal Resuscitation
Through the 145 births registered, 12 newborns (8.3%) were resuscitated for lower Apgar score. The average duration of resuscitation was 2.1 ± 0.1 minutes with extremes of 2 minutes and 3 minutes.
4.1. Limitations of the Study
The presence of investigators in the department may have influenced the behavior of the health workers. This is the source of possible bias that must be mentioned and taken into account in the interpretation of the results.
In our study, the delay in the care involved 216 patients that to say 8.2% of admissions. This result is comparable to Soma’s  who found a frequency of 8.7%. However, it is lower than Sanou’s  reported 49.4% in Ouagadougou. The differences between the series could be explained by the difference in the inclusion criteria. The high workload and low carrying capacity of the department may also explain the inability of practitioners.
4.3. Waiting Period
In our study, the average waiting period between the arrival of the patient and the beginning of first aid was 142.7 ± 13.5 minutes (2 h 23 min) with extremes of 16 and 546 minutes (9 h 6 min). Our results are poor compared to those of Coutin  which reported an average waiting time of 18 minutes 37 minutes at obstetrics and gynecology. They are also poor, compared to those of Mbola  and Saizonou  which both reported an average delay of 30 minutes. The limited capacity of our emergency service, the limited number of operating room, the lack of staff of the guard team of operators and anesthetists could help to explain the situation.
4.4. Factors of Delay
In our study, the unavailability of the operating room was cited in 61.1% of cases, lack of examination tables in 24.1%, ignorance of the places in 14.8%, the lack of money in 15.7%, closing the pharmaceutical depot in 8.3% and incomplete kits in 8.8%. Our results are similar to those of Mayi-Tsonga  who also found that the main causes of delay in care were the unavailability of the operating room in 53% of cases, the occupation of the duty surgeon by another intervention in 53%, the absence of cloths and/or sterile instruments in 61% and the absence of anesthetics in 33% of cases.
Inadequate human resources and materials in developing countries are a veritable gangrene which hinders the fight against maternal mortality  . Also the poverty of our people and their illiteracies do not play in favor of the fight against maternal mortality. The government of Burkina Faso through the grant of obstetric and neonatal emergencies wanted to improve access to emergency care. But it is clear that difficulties persist and alienating those big efforts. The number of patients seeking gynecological and obstetric emergencies and poor infrastructure make it difficult to optimize emergency care. Urgent consultations are needed between practitioners and policy makers to reposition the subsidy policy.
4.5. Prognostic Aspects
・ Maternal morbidity
Maternal complications were noted in 13.4% of patients in our series. Our results are lower than Ido’s  who reported 28.1% in the same department, some years before. The difference between these figures could be explained by the perceptible positive impact of the grant. The workload of medical staff and the unavailability of the operating room are independent factors of the quality of care.
・ Maternal mortality
We recorded 0.1% of maternal deaths. This result is lower than Kaboré’s  who found a fatality rate of 3%. Despite the significant contribution of the grant, families continue to discuss financial difficulties and some support kits are incomplete. Also the low capacity of health facilities is a real obstacle to the success of achieving the Millennium Development. It is urgent to initiate reflection on completely free obstetric and neonatal emergencies like many countries in the sub region as Benin or Mali.
・ Fetal morbi-mortality
A birth death was noted in 13.8% of newborns whose causes were dominated by neonatal pain. Our results, although slightly better than those of kaboré  , are unacceptable for a country that aspires to emerge. Late administration of care in relation to the overload of medical personnel, unavailability of the operating room, the altered state of patients due to long distances to the reference center of the fetus are weakening factors born with a low Apgar score  . Also the distance from the neonatal unit compared to the obstetrics and gynecology department is not to the advantage of newborns; some dying for lack of adequate resuscitation.
Despite the initiation by the government to subsidy for deliveries and emergency obstetric care, there remains delay in the hospital care. Patients concerned by this delay are young women living in unfavorable socioeconomic conditions. A new debate between the health workers and policy makers needs to be done in order to save the patients of our hospital.
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