Maternal mortality in a rural Tanzanian hospital: fatal Jarisch-Herxheimer reaction in a case of relapsing fever in pregnancy

Relapsing fever is a disease caused by one of the species of Borrelia. It is often misdiagnosed as malaria and can have fatal complications such as the Jarisch-Herxheimer reaction (JHR) after the commencement of treatment with antibiotics. A 19-year-old Tanzanian woman was admitted after a term home delivery that day. She presented with a 2 day history of fever, headache, general body malaise and vomiting. She was misdiagnosed as having severe malaria and was treated with quinine. The blood slide showed Borrelia duttoni. The patient continued treatment with procaine penicillin fortified for relapsing fever. Several hours later the woman died, probably due to JHR. This case of a patient with relapsing fever who died from a JHR stresses the importance of adequate diagnosis and treatment which should include careful monitoring, especially for the first hours after starting antibiotics.

Maternal near miss and mortality in a rural referral hospital in northern Tanzania: a cross-sectional study

Background

Maternal morbidity and mortality in sub-Saharan Africa remains high despite global efforts to reduce it. In order to lower maternal morbidity and mortality in the immediate term, reduction of delay in the provision of quality obstetric care is of prime importance. The aim of this study is to assess the occurrence of severe maternal morbidity and mortality in a rural referral hospital in Tanzania as proposed by the WHO near miss approach and to assess implementation levels of key evidence-based interventions in women experiencing severe maternal morbidity and mortality.

Methods

A prospective cross-sectional study was performed from November 2009 until November 2011 in a rural referral hospital in Tanzania. All maternal near misses and maternal deaths were included. As not all WHO near miss criteria were applicable, a modification was used to identify cases. Data were collected from medical records using a structured data abstraction form. Descriptive frequencies were calculated for demographic and clinical variables, outcome indicators, underlying causes, and process indicators.

Results

In the two-year period there were 216 maternal near misses and 32 maternal deaths. The hospital-based maternal mortality ratio was 350 maternal deaths per 100,000 live births (95% CI 243–488). The maternal near miss incidence ratio was 23.6 per 1,000 live births, with an overall case fatality rate of 12.9%. Oxytocin for prevention of postpartum haemorrhage was used in 96 of 201 women and oxytocin for treatment of postpartum haemorrhage was used in 38 of 66 women. Furthermore, eclampsia was treated with magnesium sulphate in 87% of all cases. Seventy-four women underwent caesarean section, of which 25 women did not receive prophylactic antibiotics. Twenty-eight of 30 women who were admitted with sepsis received parenteral antibiotics. The majority of the cases with uterine rupture (62%) occurred in the hospital.

Conclusion

Maternal morbidity and mortality remain challenging problems in a rural referral hospital in Tanzania. Key evidence-based interventions are not implemented in women with severe maternal morbidity and mortality. Progress can be made through up scaling the use of evidence-based interventions, such as the use of oxytocin for prevention and treatment of postpartum haemorrhage.

A protocol for a systematic review of birth preparedness and complication readiness programs

BACKGROUND

One of the effective strategies for reducing the number of maternal deaths is delivery by a skilled birth attendant. Low utilization of skilled birth attendants has been attributed to delay in seeking care, delay in reaching a health facility and delay in receiving adequate care. Health workers could play a role in helping women prepare for birth and anticipate complications, in order to reduce delays. There is little evidence to support these birth preparedness and complication readiness (BP/CR) programs; however, BP/CR programs are frequently implemented. The objective of this review is to assess the effect of BP/CR programs on increasing skilled birth attendance in low-resource settings.

METHODS

Due to the complexity of BP/CR programs and the need to understand why certain programs are more effective than others, we will combine both quantitative and qualitative studies in this systematic review. Search terms were selected with the assistance of a health information specialist. Three reviewers will independently select and assess studies for quality. Data will be extracted by one reviewer and checked for accuracy and completeness by a second reviewer. Discussion between the reviewers will resolve disagreements. If disagreements remain, a third party will be consulted. Data analysis will be carried out in accordance with the BP/CR matrix, developed by the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO). Study data will be grouped and analyzed by quality and study design and regrouped according to type of intervention strategy.

DISCUSSION

This review will provide: 1) an insight into existing BP/CR programs, 2) recommendations on effective elements of the different approaches, 3) proposals for concrete action plans for health professionals in the field of reproductive health in resource-poor settings and 4) an overview of existing knowledge gaps requiring further research.

TRIAL REGISTRATION

PROSPERO registration no.: CRD42012003124.

The WHO maternal near miss approach: consequences at Malawian District level

INTRODUCTION

WHO proposes a set of organ-failure based criteria for maternal near miss. Our objective was to evaluate what implementation of these criteria would mean for the analysis of a cohort of 386 women in Thyolo District, Malawi, who sustained severe acute maternal morbidity according to disease-based criteria.

METHODS AND FINDINGS

A WHO Maternal Near Miss (MNM) Tool, created to compare disease-, intervention- and organ-failure based criteria for maternal near miss, was completed for each woman, based on a review of all available medical records. Using disease-based criteria developed for the local setting, 341 (88%) of the 386 women fulfilled the WHO disease-based criteria provided by the WHO MNM Tool, 179 (46%) fulfilled the intervention-based criteria, and only 85 (22%) the suggested organ-failure based criteria.

CONCLUSIONS

In this low-resource setting, application of these organ-failure based criteria that require relatively sophisticated laboratory and clinical monitoring underestimates the occurrence of maternal near miss. Therefore, these criteria and the suggested WHO approach may not be suited to compare maternal near miss across all settings.

Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries

BACKGROUND

A maternity waiting home (MWH) is a facility within easy reach of a hospital or health centre which provides emergency obstetric care (EmOC). Women may stay in the MWH at the end of their pregnancy and await labour. Once labour starts, women move to the health facility so that labour and giving birth can be assisted by a skilled birth attendant. The aim of the MWH is to improve accessibility to skilled care and thus reduce morbidity and mortality for mother and neonate should complications arise. Some studies report a favourable effect on the outcomes for women and their newborns. Others show that utilisation is low and barriers exist. However, these data are limited in their reliability.

OBJECTIVES

To assess the effects of a maternity waiting facility on maternal and perinatal health.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 January 2012), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to January 2012), EMBASE (1980 to January 2012), CINAHL (1982 to January 2012), African Journals Online (AJOL) (January 2012), POPLINE (January 2012), Dissertation Abstracts (January 2012) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomised controlled trials including quasi-randomised and cluster-randomised trials that compared perinatal and maternal outcome in women using a MWH and women who did not.

DATA COLLECTION AND ANALYSIS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

MAIN RESULTS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effectiveness of maternity waiting facilities for improving maternal and neonatal outcomes.

Maternal mortality and severe maternal morbidity from acute fatty liver of pregnancy in the Netherlands

OBJECTIVE

To assess maternal death and severe maternal morbidity from acute fatty liver of pregnancy (AFLP) in the Netherlands.

STUDY DESIGN

A retrospective study of all cases of maternal mortality in the Netherlands between 1983 and 2006 and all cases of severe maternal morbidity in the Netherlands between 2004 and 2006, in which all 98 maternity units in the Netherlands participated. Maternal mortality ratio (MMR) and incidence of severe maternal morbidity were the main outcome measures.

RESULTS

The MMR from direct maternal mortality from AFLP was 0.13 per 100,000 live births (95% CI 0.05-0.29). The incidence of severe maternal morbidity from AFLP was 3.2 per 100,000 deliveries (95% CI 1.8-5.7).

CONCLUSIONS

AFLP is a rare condition which still causes severe maternal morbidity and in some cases mortality. Referral to a tertiary care hospital for treatment of this uncommon disease should be considered.

Improvement of maternal health services through the use of mobile phones

OBJECTIVE

To analyse, on the basis of the literature, the potential of mobile phones to improve maternal health services in Low and Middle Income Countries (LMIC).

METHODS

Wide search for scientific and grey literature using various terms linked to: maternal health, mobile telecommunication and LMIC. Applications requiring an internet connection were excluded as this is not widely available in LMIC yet.

RESULTS

Few projects exist in this field and little evidence is available as yet on the impact of mobile phones on the quality of maternal health services. Projects focus mainly on the delay in receiving care--that is in recognizing the need and making the decision to seek care--and the delay in arriving at the health facility. This is achieved by connecting lesser trained health workers to specialists and coordination of referrals. Ongoing projects focus on empowering women to seek health care.

DISCUSSION

There is broad agreement that access to communication is one of several essential components to improve maternal health services and hence the use of mobile phones has much potential. However, there is a need for robust evidence on constraints and impacts, especially when financial and human resources will be invested. Concurrently, other ways in which mobile phones can be used to benefit maternal health services need to be further explored, taking into consideration privacy and confidentiality.

Treatment of uterine prolapse stage 2 or higher: a randomized multicenter trial comparing sacrospinous fixation with vaginal hysterectomy (SAVE U trial)

BACKGROUND

Pelvic organ prolapse is a common health problem, affecting up to 40% of parous women over 50 years old, with significant negative influence on quality of life. Vaginal hysterectomy is currently the leading treatment method for patients with symptomatic uterine prolapse. Several studies have shown that sacrospinous fixation in case of uterine prolapse is a safe and effective alternative to vaginal hysterectomy. However, no large randomized trials with long-term follow-up have been performed to compare efficacy and quality of life between both techniques.The SAVE U trial is designed to compare sacrospinous fixation with vaginal hysterectomy in the treatment of uterine prolapse stage 2 or higher in terms of prolapse recurrence, quality of life, complications, hospital stay, post-operative recovery and sexual functioning.

METHODS/DESIGN

The SAVE U trial is a randomized controlled multi-center non-inferiority trial. The study compares sacrospinous fixation with vaginal hysterectomy in women with uterine prolapse stage 2 or higher. The primary outcome measure is recurrence of uterine prolapse defined as: uterine descent stage 2 or more assessed by pelvic organ prolapse quantification examination and prolapse complaints and/or redo surgery at 12 months follow-up. Secondary outcomes are subjective improvement in quality of life measured by generic (Short Form 36 and Euroqol 5D) and disease-specific (Urogenital Distress Inventory, Defecatory Distress Inventory and Incontinence Impact Questionnaire) quality of life instruments, complications following surgery, hospital stay, post-operative recovery and sexual functioning (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire). Analysis will be performed according to the intention to treat principle. Based on comparable recurrence rates of 3% and considering an upper-limit of 7% to be non-inferior (beta 0.2 and one sided alpha 0.025), 104 patients are needed per group.

DISCUSSION

The SAVE U trial is a randomized multicenter trial that will provide evidence whether the efficacy of sacrospinous fixation is similar to vaginal hysterectomy in women with uterine prolapse stage 2 or higher.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR1866.

[Crisis in human resources for health: millennium development goals for maternal and child health threatened]

International migration of health care workers from low-income countries to the West has increased considerably in recent years, thereby jeopardizing the achievements of The Millennium Development Goals, especially number 4 (reduction of child mortality) and 5 (improvement of maternal health).This migration, as well as the HIV/AIDS epidemic, lack of training of health care personnel and poverty, are mainly responsible for this health care personnel deficit. It is essential that awareness be raised amongst donors and local governments so that staffing increases, and that infection prevention measures be in place for their health care personnel. Western countries should conduct a more ethical recruitment of health care workers, otherwise a new millennium development goal will have to be created: to reduce the human resources for health crisis.

Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries

BACKGROUND

A Maternity Waiting Home (MWH) is a facility, within easy reach of a hospital or health centre which provides Emergency Obstetric Care (EmOC). Women may stay in the MWH at the end of their pregnancy and await labour. Once labour starts, women move to the health facility so that labour and giving birth may be assisted by a skilled birth attendant. The aim of the MWH is to improve accessibility and thus reduce morbidity and mortality for mother and neonate should complications arise. Some studies report a favourable effect on the outcomes for women and their newborn. Others show that utilisation is low and barriers exist. However these data are limited in reliability.

OBJECTIVES

To assess the effects of a maternity waiting facility on maternal and perinatal health.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009), CENTRAL (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to April 2009), EMBASE (1980 to April 2009), CINAHL (1982 to April 2009), African Journals Online (AJOL) (April 2009), POPLINE (April 2009), Dissertation Abstracts (April 2009) and the National Research Register archive (March 2008).

SELECTION CRITERIA

Randomised controlled trials including quasi-randomised and cluster-randomised trials that compared perinatal and maternal outcome in women using a MWH and women who did not.

DATA COLLECTION AND ANALYSIS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

MAIN RESULTS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effectiveness of Maternity Waiting Facilities for improving maternal and neonatal outcomes.

Skilled or traditional birth attendant? Choices of communities in Lukulu District, rural Zambia

OBJECTIVE

To analyse factors that contribute to the choice of either traditional birth attendants (TBAs) or skilled birth attendants (SBAs) by inhabitants of Zambia's Lukulu District.

DESIGN

Cross-sectional descriptive survey.

SETTINGS

Lukulu District, Western Province, Zambia.

POPULATION

1413 participants: parous women, their husbands, village headmen and elderly women.

MAIN OUTCOME MEASURES

Preferred and actual place of birth.

METHODS

Questionnaires, structured interviews and focus group discussions.

RESULTS

42% of women gave birth in a health facility, assisted by SBAs; 75: prefer to give birth in a health facility; many barriers are to be passed for women to reach a skilled attendant in time.

CONCLUSION

Skilled birth attendants are preferred to assist at childbirth in Lukulu District. Transportation problems, sociocultural reasons and unpreparedness still cause the majority of women to turn to traditional birth attendants. Traditional birth attendants should not yet be excluded from safe motherhood programs.

[Malignant struma ovarii]

A 46-year-old patient underwent exploratory laparotomy due to indications of ovarian malignancy. Bilateral salpingooophorectomy, total abdominal hysterectomy, omentectomy and lymphadenectomy were performed, but no residual tumour was seen. Histopathological examination of postoperative specimens revealed malignant struma ovarii, a very rare condition. The patient had a low risk of disease progression (T1>1cmN0M0). Management consisted of initial conservative follow-up, which included administration of thyroid-stimulating hormone (TSH) suppression therapy with levothyroxine.

The use of audit to identify maternal mortality in different settings: is it just a difference between the rich and the poor?

OBJECTIVE

To illustrate how maternal mortality audit identifies different causes of and contributing factors to maternal deaths in different settings in low- and high-income countries and how this can lead to local solutions in reducing maternal deaths.

DESIGN

Descriptive study of maternal mortality from different settings and review of data on the history of reducing maternal mortality in what are now high-income countries.

SETTINGS

Kalabo district in Zambia, Farafenni division in The Gambia, Onandjokwe district in Namibia, and The Netherlands.

POPULATION

Population of rural areas in Zambia and The Gambia, peri-urban population in Namibia and nationwide data from The Netherlands.

METHODS

Data from facility-based maternal mortality audits from three African hospitals and data from the latest confidential enquiry in The Netherlands.

MAIN OUTCOME MEASURES

Maternal mortality ratio (MMR), causes (direct and indirect) and characteristics.

RESULTS

MMR ranged from 10 per 100,000 (The Netherlands) to 1,540 per 100,000 (The Gambia). Differences in causes of deaths were characterized by HIV/AIDS in Namibia, sepsis and HIV/AIDS in Zambia, (pre-)eclampsia in The Netherlands and obstructed labour in The Gambia.

CONCLUSION

Differences in maternal mortality are more than just differences between the rich and poor. Acknowledging the magnitude of maternal mortality and harnessing a strong political will to tackle the issues are important factors. However, there is no single, general solution to reduce maternal mortality, and identification of problems needs to be promoted through audit, both national and local.

The use of audit to identify maternal mortality in different settings: is it just a difference between the rich and the poor?

OBJECTIVE

To illustrate how maternal mortality audit identifies different causes of and contributing factors to maternal deaths in different settings in low- and high-income countries and how this can lead to local solutions in reducing maternal deaths.

DESIGN

Descriptive study of maternal mortality from different settings and review of data on the history of reducing maternal mortality in what are now high-income countries.

SETTINGS

Kalabo district in Zambia, Farafenni division in The Gambia, Onandjokwe district in Namibia, and the Netherlands.

POPULATION

Population of rural areas in Zambia and The Gambia, peri-urban population in Namibia and nationwide data from The Netherlands.

METHODS

Data from facility-based maternal mortality audits from three African hospitals and data from the latest confidential enquiry in The Netherlands.

MAIN OUTCOME MEASURES

Maternal mortality ratio (MMR), causes (direct and indirect) and characteristics.

RESULTS

MMR ranged from 10 per 100,000 (the Netherlands) to 1540 per 100,000 (The Gambia). Differences in causes of deaths were characterized by HIV/AIDS in Namibia, sepsis and HIV/AIDS in Zambia, (pre-)eclampsia in the Netherlands and obstructed labour in The Gambia.

CONCLUSION

Differences in maternal mortality are more than just differences between the rich and poor. Acknowledging the magnitude of maternal mortality and harnessing a strong political will to tackle the issues are important factors. However, there is no single, general solution to reduce maternal mortality, and identification of problems needs to be promoted through audit, both national and local.

The use of audit to identify maternal mortality in different settings: is it just a difference between the rich and the poor?

OBJECTIVE

To illustrate how maternal mortality audit identifies different causes of and contributing factors to maternal deaths in different settings in low- and high-income countries and how this can lead to local solutions in reducing maternal deaths.

DESIGN

Descriptive study of maternal mortality from different settings and review of data on the history of reducing maternal mortality in what are now high-income countries.

SETTINGS

Kalabo district in Zambia, Farafenni division in The Gambia, Onandjokwe district in Namibia, and the Netherlands.

POPULATION

Population of rural areas in Zambia and The Gambia, peri-urban population in Namibia and nationwide data from the Netherlands.

METHODS

Data from facility-based maternal mortality audits from three African hospitals and data from the latest confidential enquiry in the Netherlands.

MAIN OUTCOME MEASURES

Maternal mortality ratio (MMR), causes (direct and indirect) and characteristics.

RESULTS

MMR ranged from 10 per 100,000 (the Netherlands) to 1,540 per 100,000 (The Gambia). Differences in causes of deaths were characterized by HIV/AIDS in Namibia, sepsis and HIV/AIDS in Zambia, (pre-)eclampsia in The Netherlands and obstructed labour in The Gambia.

CONCLUSION

Differences in maternal mortality are more than just differences between the rich and poor. Acknowledging the magnitude of maternal mortality and harnessing a strong political will to tackle the issues are important factors. However, there is no single, general solution to reduce maternal mortality, and identification of problems needs to be promoted through audit, both national and local.

[The UN Millennium Project; especially the prevention and treatment of the HIV-virus and AIDS in order to reduce child and maternal mortality]

Reducing child and maternal mortality are important UN Millennium Development Goals. The AIDS epidemic, which is targeted in another Millennium Development Goal, has a negative influence on child and maternal health. Although on a mondial level, the influence of HIV/AIDS on child and maternal mortality appears to be slight, HIV/AIDS constitutes a significant factor in Sub-Saharan Africa. In the Netherlands, the introduction of aggressive antiretroviral therapy has reduced the chance of vertical transmission to < 1%. In low-wage countries, financial means and political commitment for similar handling are lacking. Possible strategies for the prevention of vertical transmission for these countries are as follows: multivitamin supplements during pregnancy, prophylaxis against opportune infections with cotrimoxazol, a vaginal douche with chlorhexidine for cases where the membranes have ruptured more than 4 hours previously, and a single dose of nevirapine.

[The Millennium project of the United Nations, focusing on adequate postpartum care to reduce maternal and neonatal mortality world-wide]

One of the goals of the Millennium project of the United Nations is to reduce maternal and infant mortality. This includes adequate care for mothers and newborns during childbirth. Most maternal deaths occur during the post-partum period. Postpartum haemorrhage, eclampsia and sepsis are the main causes of maternal death. Preventive measures include active management of the third stage of labour, use of magnesium sulphate in pre-eclampsia, and implementing hygienic birth practices and the use of antibiotics, respectively. Major causes of neonatal mortality are pre- and dysmaturity, infections, congenital abnormalities and birth trauma, including asphyxia. The kangaroo-method can reduce morbidity in premature infants. The use of hygienic practices and antibiotics decreases the number of newborn deaths due to infection. Antiretroviral therapy is effective in preventing mother-to-child transmission of HIV. In many resource poor countries formula feeding is not feasible and the WHO advises exclusive breastfeeding for HIV positive women in these settings. A formula of 6 hours, 6 days, 6 weeks and 6 months after birth is recommended by the WHO to check the condition of mother and baby. This should be integrated in mother and child health clinics and also includes child vaccinations and counselling the mother on family planning and prevention of sexually transmitted diseases.

[The Millennium project of the United Nations, particularly the worldwide reduction of childhood and maternal mortality]

This year (2005) marks a pivotal moment in the achievement of the so-called Millennium Development Goals (MDGs) of the United Nations. This article pays attention to 2 of the 8 MDGs, namely those pertaining to childhood and maternal mortality. A number of aspects are of crucial importance to the reduction of childhood and maternal mortality: reduction of the number of (unwanted) pregnancies, worldwide access for women to high-quality healthcare services including prenatal care, care during delivery and postnatal care, and improvement of the referral systems. The impact of the HIV/AIDS epidemic on the outcome of pregnancy is discussed separately.

Health care seeking behaviour and utilisation of traditional healers in Kalabo, Zambia

OBJECTIVE

To identify traditional healers in the catchment area of Kalabo District Hospital and to investigate determinants which play a role in the choice between different health care options, and to explore possibilities for increasing co-operation between the District Hospital and traditional healers.

METHODS

In a cross-sectional comparative and descriptive study, a combination of both quantitative and qualitative methods was used. A total of 12 health workers, 13 traditional healers and 100 community representatives were interviewed, using (semi)-structured questionnaires. A focus group discussion was held with 12 traditional healers.

RESULTS

This study shows that all respondents are willing to visit the hospital if they fall ill in future, and 88% of the respondents will visit a traditional healer. More women than men visit traditional healers, but the men who do visit them, do so more frequently. Level of education is not an important determinant. Increasing age leads to more frequent visits to both the hospital and traditional healers. Almost half of the respondents (49%) only have to walk less than 30 min to a traditional healer, but the hospital is the same distance for only 34% of the respondents. Waiting time turned out to be an important factor: in the hospital, 48% of the respondents are not helped within time, and only 28% are not helped in time by the traditional healer. Demon possession, mbaci, kanono and infertility are typical health problems for which people visit a traditional healer. The cost of treatment from a traditional healer is usually one cow, but only if the patient is cured. Satisfaction was measured at 89% after hospital treatment, and 74% after treatment from a traditional healer. If dissatisfied with the traditional healer, 86% would consider attending the hospital.