title: Assisted vaginal delivery in low and middle income countries: an overview.
abstract: OBJECTIVE
  To assess the use of assisted vaginal delivery (AVD) in low- and middle-income countries (LMICs), highlighting what level of care procedures were performed and identifying systemic barriers to its use.
  
  
  METHODS
  Cross-sectional health facility assessments.
  
  
  METHODS
  Up to 40 countries in Latin America, sub-Saharan Africa and Asia.
  
  
  METHODS
  Assessments tended to be national in scope and included all hospitals and samples of midlevel facilities in public and private sectors.
  
  
  METHODS
  Descriptive secondary data analysis.
  
  
  METHODS
  Percentage of facilities where health workers performed AVD in the 3 months prior to the assessment, instrument preference, which health workers performed the procedure, and reasons AVD was not practiced.
  
  
  RESULTS
  Fewer than 20% of facilities in Latin America reported performing AVD in the last 3 months. In sub-Saharan Africa, 53% of 1728 hospitals had performed AVD but only 6% of nearly 10 000 health centres had done so. It was not uncommon to find <1% of institutional births delivered by AVD. Vacuum extraction appears preferred over forceps. Lack of equipment and trained health workers were the most frequent reasons for non-performance.
  
  
  CONCLUSIONS
  The low use of AVD in LMICs is in contrast with many high-income countries, where high caesarean rates are also associated with significant rates of AVD. In many LMICs, rising caesarean rates have not been associated with maintenance of skills and practice of AVD. AVD is underused precisely in countries where pregnant women continue to face hardships accessing emergency obstetric care and where caesarean delivery can be relatively unsafe.
  
  
  CONCLUSIONS
  Many LMICs exhibit low use of assisted vaginal delivery where access to EmONC continues to be a hardship.
authors.affiliation: Global Health Programs, FHI 360, Durham, NC, USA.|Averting Maternal Death & Disability, Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA.
authors.forename: P E
authors.initials: PE
authors.lastname: Bailey
authors.affiliation: Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands.|Athena Institute, VU University, Amsterdam, The Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: van Roosmalen
authors.affiliation: School of Medicine and Health Sciences, Port Moresby General Hospital, Port Moresby, NCD, Papua New Guinea.
authors.forename: G
authors.initials: G
authors.lastname: Mola
authors.affiliation: Global Learning Office, Jhpiego, Baltimore, MD, USA.
authors.forename: C
authors.initials: C
authors.lastname: Evans
authors.affiliation: Auriolles, Bias, France.
authors.forename: L
authors.initials: L
authors.lastname: de Bernis
authors.affiliation: Jhpiego, Baltimore, MD, USA.
authors.forename: B
authors.initials: B
authors.lastname: Dao
mesh_terms: D003430:Cross-Sectional Studies; D003906:Developing Countries / Q000706:statistics & numerical data*; D005113:Extraction, Obstetrical / Q000295:instrumentation / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D014943:Global Health; D006801:Humans; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011247:Pregnancy
keywords: Assisted vaginal delivery; caesarean delivery; forceps; vacuum extraction