Table 2.

Interventions

Intervention	Description
Training of provincial pilot team	• recommended use of vacuum extraction by MCH nurses, doctors or obstetricians to shorten the second phase of labour for maternal or foetal benefits, allowing a maximum of three tractions to achieve childbirth, with referral and caesarean section as alternative. Its use was based on four criteria: 1) complete dilatation of the cervix; 2) cephalic presentation; 3) gestational age at term; 4) descent of the presenting part at the third or fourth planes of Hodge;
	• coincided with the introduction of hand-held devices for vacuum extractions (Kiwi™ Omnicup, sterilisable version), easy to use although with little resistance to regular re-use; an additional number of vacuum extraction cups (both metal and silicon) and pumps (hand-operated, foot-operated or electrical) were already available;
	• staff were encouraged to experiment with the assembly of a functional vacuum extractor with any available types of cup and pump and to practice regularly (at least once a month) to gain experience and promote emergency preparedness;
	• no other staff received additional formal training to perform vacuum extraction, but clinicians at the provincial hospital were assigned to provide in-service training to any MCH nurse or doctor wishing to strengthen their capabilities;
	• sharing of capabilities between staff at district or health facility level was actively encouraged and regularly occurred (as shown by photos and comments in the relevant WhatsApp groups), with or without additional facilitation from provincial level.
Monitoring and evaluation	• the quarterly emergency obstetric care accreditation process was based exclusively on routine data in the provincial health information system;
	• each quarter, data from all participating health facilities were compiled in a spreadsheet with numeric and graphic representations of performance, focussing on vacuum extractions and health facilities accredited in emergency obstetric care; these results were included in the routinely prepared quarterly performance reports of the provincial health sector.
Audit	• a monthly audit of clinical files of all cases of caesarean section in the provincial hospital was performed from January 2015 till September 2016 (and once more for March 2017) by a locally-based international technical advisor, not directly involved in patient care;
	• focussed on the appropriateness of the indication for caesarean section and previous use of less invasive methods to accelerate labour;
	• a caesarean section was considered unavoidable in case of: lack of progress after artificial rupture of membranes and augmentation with oxytocin, repeated failed induction of labour with misoprostol, failed attempt at vacuum extraction, two or more previous caesarean sections, placental abruption, non-cephalic presentation with present foetal heartbeat, ruptured uterus, placenta praevia, or cord prolapse with present foetal heartbeat, as documented in the clinical files;
Feedback	• quarterly feedback on the accreditation in emergency obstetric care was provided via email and Whatsapp groups to provincial managers, district directors, district medical officers, and hospital obstetric staff, after a previous reminder to pay extra attention to health facilities which were close to accreditation based on data from the first two months of each quarter;
	• monthly feedback of the audit results was provided to clinicians involved included the percentage of potentially avoidable caesarean sections per clinician, visible to the whole team.
	• well performing MCH nurses, doctors, health facilities and districts were praised in the relevant WhatsApp groups, while others were encouraged to follow their example and try harder;
	• in 2016, the staff of one health facility and the corresponding district health director and doctor which managed to achieve accreditation in six consecutive quarters, as only health facility in the entire province, received public recognition and a prize in the principal annual provincial health sector meeting; several districts also organized prize- and recognition ceremonies for well performing staff and health facilities at local level;
	• due to staff changes at provincial level affecting the chief medical officer, chief public health officer, MCH manager and locally-based international technical advisor, the accreditation process received less attention in 2017 and specific feedback was not provided.