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Bergh AM, Allanson E, Pattinson RC. What is needed for taking emergency obstetric and neonatal programmes to scale? Best Pract Res Clin Obstet Gynaecol 2015; 29:1017-27. [PMID: 25921973 DOI: 10.1016/j.bpobgyn.2015.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 03/16/2015] [Indexed: 11/24/2022]
Abstract
Scaling up an emergency obstetric and neonatal care (EmONC) programme entails reaching a larger number of people in a potentially broader geographical area. Multiple strategies requiring simultaneous attention should be deployed. This paper provides a framework for understanding the implementation, scale-up and sustainability of such programmes. We reviewed the existing literature and drew on our experience in scaling up the Essential Steps in the Management of Obstetric Emergencies (ESMOE) programme in South Africa. We explore the non-linear change process and conditions to be met for taking an existing EmONC programme to scale. Important concepts cutting across all components of a programme are equity, quality and leadership. Conditions to be met include appropriate awareness across the board and a policy environment that leads to the following: commitment, health systems-strengthening actions, allocation of resources (human, financial and capital/material), dissemination and training, supportive supervision and monitoring and evaluation.
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Affiliation(s)
- Anne-Marie Bergh
- Maternal and Infant Health Care Strategies Research Unit, Medical Research Council of South Africa and Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Emma Allanson
- School of Women's and Infants' Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia and Medical Research Council South Africa, Maternal and Infant Health Care Strategies Unit, Pretoria, South Africa
| | - Robert C Pattinson
- Maternal and Infant Health Care Strategies Research Unit, Medical Research Council of South Africa and Clinical Head, Obstetrics and Gynaecology Department, Kalafong Hospital, University of Pretoria, Pretoria, South Africa.
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Timša L, Marrone G, Ekirapa E, Waiswa P. Strategies for helping families prepare for birth: experiences from eastern central Uganda. Glob Health Action 2015; 8:23969. [PMID: 25843492 PMCID: PMC4385208 DOI: 10.3402/gha.v8.23969] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 06/15/2014] [Accepted: 09/11/2014] [Indexed: 11/14/2022] Open
Abstract
Background Promotion of birth preparedness and raising awareness of potential complications is one of the main strategies to enhance the timely utilisation of skilled care at birth and overcome barriers to accessing care during emergencies. Objective This study aimed to investigate factors associated with birth preparedness in three districts of eastern central Uganda. Design This was a cross-sectional baseline study involving 2,010 women from Iganga [community health worker (CHW) strategy], Buyende (vouchers for transport and services), and Luuka (standard care) districts who had delivered within the past 12 months. ‘Birth prepared’ was defined as women who had taken all of the following three key actions at least 1 week prior to the delivery: 1) chosen where to deliver from; 2) saved money for transport and hospital costs; and 3) bought key birth materials (a clean instrument to cut the cord, a clean thread to tie the cord, cover sheet, and gloves). Logistical regression was performed to assess the association of various independent variables with birth preparedness. Results Only about 25% of respondents took all three actions relating to preparing for childbirth, but discrete actions (e.g. financial savings and identification of place to deliver) were taken by 75% of respondents. Variables associated with being prepared for birth were: having four antenatal care (ANC) visits [adjusted odds ratio (ORA)=1.42; 95% confidence interval (CI) 1.10–1.83], attendance of ANC during the first (ORA=1.94; 95% CI 1.09–3.44) or second trimester (ORA=1.87; 95% CI 1.09–3.22), and counselling on danger signs during pregnancy or on place of referral (ORA=2.07; 95% CI 1.57–2.74). Other associated variables included being accompanied by one's husband to the place of delivery (ORA=1.47; 95% CI 1.15–1.89), higher socio-economic status (ORA=2.04; 95% CI 1.38–3.01), and having a regular income (ORA=1.83; 95% CI 1.20–2.79). Women from Luuka and Buyende were less likely to have taken three actions compared with women from Iganga (ORA=0.72; 95% CI 0.54–0.98 and ORA=0.37; 95% CI 0.27–0.51, respectively). Conclusions Engaging CHWs and local structures during pregnancy may be an effective strategy in promoting birth preparedness. On the other hand, if not well designed, the use of vouchers could disempower families in their efforts to prepare for birth. Other effective strategies for promoting birth preparedness include early ANC attendance, attending ANC at least four times, and male involvement.
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Affiliation(s)
- Līga Timša
- Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden;
| | - Gaetano Marrone
- Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth Ekirapa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
| | - Peter Waiswa
- Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
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Kerber K, Peterson S, Waiswa P. Special issue: newborn health in Uganda. Glob Health Action 2015; 8:27574. [PMID: 25843501 PMCID: PMC4385224 DOI: 10.3402/gha.v8.27574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Stefan Peterson
- Makerere University, Kampala, Uganda
- Karolinska Institutet, Stockholm, Sweden
- Uppsala University, Uppsala, Sweden
- Iganga/Mayuge Health Demographic Surveillance Site, Kampala, Uganda
| | - Peter Waiswa
- Makerere University, Kampala, Uganda
- Karolinska Institutet, Stockholm, Sweden
- Iganga/Mayuge Health Demographic Surveillance Site, Kampala, Uganda
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Raman S, Iljadica A, Gyaneshwar R, Taito R, Fong J. Improving maternal and child health systems in Fiji through a perinatal mortality audit. Int J Gynaecol Obstet 2015; 129:165-8. [PMID: 25636710 DOI: 10.1016/j.ijgo.2014.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 11/04/2014] [Accepted: 01/09/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop a standardized process of perinatal mortality audit (PMA) and improve the capacity of health workers to identify and correct factors underlying preventable deaths in Fiji. METHODS In a pilot study, clinicians and healthcare managers in obstetrics and pediatrics were trained to investigate stillbirths and neonatal deaths according to current guidelines. A pre-existing PMA datasheet was refined for use in Fiji and trialed in three divisional hospitals in 2011-12. Key informant interviews identified factors influencing PMA uptake. RESULTS Overall, 141 stillbirths and neonatal deaths were analyzed (57 from hospital A and 84 from hospital B; forms from hospital C excluded because incomplete/illegible). Between-site variations in mortality were recorded on the basis of the level of tertiary care available; 28 (49%) stillbirths were recorded in hospital A compared with 53 (63%) in hospital B. Substantial health system factors contributing to preventable deaths were identified, and included inadequate staffing, problems with medical equipment, and lack of clinical skills. Leadership, teamwork, communication, and having a standardized process were associated with uptake of PMA. CONCLUSION The use of PMAs by health workers in Fiji and other Pacific island countries could potentially rectify gaps in maternal and neonatal service delivery.
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Affiliation(s)
- Shanti Raman
- Department of Community Paediatrics, Liverpool Hospital, South Western Sydney Local Health District, Liverpool, NSW, Australia.
| | - Alexandra Iljadica
- Discipline of International Business, University of Sydney, Camperdown, NSW, Australia
| | - Rajat Gyaneshwar
- College of Medicine, Nursing and Health Sciences, Lautoka Hospital, Fiji National University, Lautoka, Fiji
| | - Rigamoto Taito
- College of Medicine, Nursing and Health Sciences, Lautoka Hospital, Fiji National University, Lautoka, Fiji
| | - James Fong
- Department of Obstetrics and Gynecology, Colonial War Memorial Hospital, Suva, Fiji
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Singh K, Brodish P, Suchindran C. A regional multilevel analysis: can skilled birth attendants uniformly decrease neonatal mortality? Matern Child Health J 2014; 18:242-249. [PMID: 23504132 DOI: 10.1007/s10995-013-1260-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Globally 40 % of deaths to children under-five occur in the very first month of life with three-quarters of these deaths occurring during the first week of life. The promotion of delivery with a skilled birth attendant (SBA) is being promoted as a strategy to reduce neonatal mortality. This study explored whether SBAs had a protective effect against neonatal mortality in three different regions of the world. The analysis pooled data from nine diverse countries for which recent Demographic and Health Survey data were available. Multilevel logistic regression was used to understand the influence of skilled delivery on two outcomes-neonatal mortality during the first week of life and during the first day of life. Control variables included age, parity, education, wealth, residence (urban/rural), geographic region (Africa, Asia and Latin America/Caribbean), antenatal care and tetanus immunization. The direction of the effect of skilled delivery on neonatal mortality was dependent on geographic region. While having a SBA at delivery was protective against neonatal mortality in Latin America/Caribbean, in Asia there was only a protective effect for births in the first week of life. In Africa SBAs were associated with higher neonatal mortality for both outcomes, and the same was true for deaths on the first day of life in Asia. Many women in Africa and Asia deliver at home unless a complication occurs, and thus skilled birth attendants may be seeing more women with complications than their unskilled counterparts. In addition there are issues with the definition of a SBA with many attendants in both Africa and Asia not actually having the needed training and equipment to prevent neonatal mortality. Considerable investment is needed in terms of training and health infrastructure to enable these providers to save the youngest lives.
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Affiliation(s)
- Kavita Singh
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, CB# 8120, Chapel Hill, NC, 27516, USA. .,MEASURE Evaluation/Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paul Brodish
- MEASURE Evaluation/Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chirayath Suchindran
- MEASURE Evaluation/Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Berhan Y, Berhan A. Reasons for persistently high maternal and perinatal mortalities in Ethiopia: Part II-Socio-economic and cultural factors. Ethiop J Health Sci 2014; 24 Suppl:119-36. [PMID: 25489187 PMCID: PMC4249210 DOI: 10.4314/ejhs.v24i0.11s] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The major causes of maternal and perinatal deaths are mostly pregnancy related. However, there are several predisposing factors for the increased risk of pregnancy related complications and deaths in developing countries. The objective of this review was to grossly estimate the effect of selected socioeconomic and cultural factors on maternal mortality, stillbirths and neonatal mortality in Ethiopia. METHODS A comprehensive literature review was conducted focusing on the effect of total fertility rate (TFR), modern contraceptive use, harmful traditional practice, adult literacy rate and level of income on maternal and perinatal mortalities. For the majority of the data, regression analysis and Pearson correlation coefficient were used as a proxy indicator for the association of variables with maternal, fetal and neonatal mortality. RESULTS Although there were variations in the methods for estimation, the TFR of women in Ethiopia declined from 5.9 to 4.8 in the last fifteen years, which was in the middle as compared with that of other African countries. The preference of injectable contraceptive method has increased by 7-fold, but the unmet contraceptive need was among the highest in Africa. About 50% reduction in female genital cutting (FGC) was reported although some women's attitude was positive towards the practice of FGC. The regression analysis demonstrated increased risk of stillbirths, neonatal and maternal mortality with increased TFR. The increased adult literacy rate was associated with increased antenatal care and skilled person attended delivery. Low adult literacy was also found to have a negative association with stillbirths and neonatal and maternal mortality. A similar trend was also observed with income. CONCLUSION Maternal mortality ratio, stillbirth rate and neonatal mortality rate had inverse relations with income and adult education. In Ethiopia, the high total fertility rate, low utilization of contraceptive methods, low adult literacy rate, low income and prevalent harmful traditional practices have probably contributed to the high maternal mortality ratio, stillbirth and neonatal mortality rates.
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Affiliation(s)
- Yifru Berhan
- Hawassa University, College of Medicine and Health Sciences, Department of Gynecology-Obstetrics
| | - Asres Berhan
- Hawassa University, College of Medicine and Health Sciences, Department of Pharmacology
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Merali HS, Lipsitz S, Hevelone N, Gawande AA, Lashoher A, Agrawal P, Spector J. Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. BMC Pregnancy Childbirth 2014; 14:280. [PMID: 25129069 PMCID: PMC4143551 DOI: 10.1186/1471-2393-14-280] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 08/05/2014] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Audits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries. METHODS We performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews. RESULTS Thirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified. CONCLUSIONS Audits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five.
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Affiliation(s)
- Hasan S Merali
- The Hospital for Sick Children, 555 University Avenue, Toronto ON M5G 1X8, Canada.
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Upadhyay RP, Krishnan A, Rai SK, Chinnakali P, Odukoya O. Need to focus beyond the medical causes: a systematic review of the social factors affecting neonatal deaths. Paediatr Perinat Epidemiol 2014; 28:127-37. [PMID: 24354747 DOI: 10.1111/ppe.12098] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Reducing the global total of 3.3 million neonatal deaths is crucial to meeting the fourth Millennium Development Goal. Until recently, attention has been on the medical causes of the neonatal deaths, while the social factors contextualising these deaths have largely remained unaddressed. The current review aimed to quantify the role of these factors in neonatal deaths. METHODS A systematic search was performed through PubMed, Google scholar, Cochrane library, Medline, IndMed, Embase, World Health Organization and Biomed central databases. Studies published from 1995 to 2011 were included. Random effects meta-analysis was performed to derive at an estimate of the burden of delays, as defined by the 'three delays model' by Thadeus and Maine. RESULTS A total of 17 studies were reviewed. The majority of them (n = 10) were from the African continent. Level 3 delay, i.e. delay in receiving appropriate treatment upon reaching a health facility (38.7%, 95% CI, 21.7%-57.3%) and delay in deciding to seek care for the illness (Level 1 delay) (28%, 95% CI, 16%-43%) were the major contributors to neonatal deaths. Level 2 delay, i.e. delay in reaching a health facility (18.3%, 95% CI, 2.6-43.8%) contributed least to the neonatal deaths. CONCLUSION Creating awareness among caregivers regarding early recognition and treatment seeking for neonatal illness along with improving the quality of neonatal care provided at the health facilities is essential to reduce neonatal mortality.
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Affiliation(s)
- Ravi Prakash Upadhyay
- Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Hanson C, Ronsmans C, Penfold S, Maokola W, Manzi F, Jaribu J, Mbaruku G, Mshinda H, Tanner M, Schellenberg J. Health system support for childbirth care in Southern Tanzania: results from a health facility census. BMC Res Notes 2013; 6:435. [PMID: 24171904 PMCID: PMC4228478 DOI: 10.1186/1756-0500-6-435] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 10/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Progress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth. RESULTS Health centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2-3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of first-line facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months. CONCLUSIONS Essential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constrains the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive "skilled attendance" and adequate care for common obstetric complications such as post-partum haemorrhage.
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Affiliation(s)
- Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
- Department of Public Health Science (Global Health), Karolinska Institutet, Stockholm, Sweden
| | - Carine Ronsmans
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Suzanne Penfold
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
| | | | - Fatuma Manzi
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
| | - Jenny Jaribu
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Hassan Mshinda
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
- Tanzania Commission of Science and Technology (COSTECH), Dar-es-Salaam, Tanzania
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Mahande MJ, Daltveit AK, Mmbaga BT, Obure J, Masenga G, Manongi R, Lie RT. Recurrence of perinatal death in Northern Tanzania: a registry based cohort study. BMC Pregnancy Childbirth 2013; 13:166. [PMID: 23988153 PMCID: PMC3765768 DOI: 10.1186/1471-2393-13-166] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 08/27/2013] [Indexed: 11/10/2022] Open
Abstract
Background Perinatal mortality is known to be high in Sub-Saharan Africa. Some women may carry a particularly high risk which would be reflected in a high recurrence risk. We aim to estimate the recurrence risk of perinatal death using data from a hospital in Northern Tanzania. Methods We constructed a cohort study using data from the hospital based KCMC Medical Birth Registry. Women who delivered a singleton for the first time at the hospital between 2000 and 2008 were followed in the registry for subsequent deliveries up to 2010 and 3,909 women were identified with at least one more delivery within the follow-up period. Recurrence risk of perinatal death was estimated in multivariate models analysis while adjusting for confounders and accounting for correlation between births from the same mother. Results The recurrence risk of perinatal death for women who had lost a previous baby was 9.1%. This amounted to a relative risk of 3.2 (95% CI: 2.2 - 4.7) compared to the much lower risk of 2.8% for women who had had a surviving baby. Recurrence contributed 21.2% (31/146) of perinatal deaths in subsequent pregnancies. Preeclampsia, placental abruption, placenta previa, induced labor, preterm delivery and low birth weight in a previous delivery with a surviving baby were also associated with increased perinatal mortality in the next pregnancy. Conclusions Some women in Tanzanian who suffer a perinatal loss in one pregnancy are at a particularly high risk of also losing the baby of a subsequent pregnancy. Strategies of perinatal death prevention that target pregnant women who are particularly vulnerable or already have experienced a perinatal loss should be considered in future research.
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Nelissen EJT, Mduma E, Ersdal HL, Evjen-Olsen B, van Roosmalen JJM, Stekelenburg J. Maternal near miss and mortality in a rural referral hospital in northern Tanzania: a cross-sectional study. BMC Pregnancy Childbirth 2013; 13:141. [PMID: 23826935 PMCID: PMC3716905 DOI: 10.1186/1471-2393-13-141] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 06/28/2013] [Indexed: 11/14/2022] Open
Abstract
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.
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Mbwele B, Ide NL, Reddy E, Ward SAP, Melnick JA, Masokoto FA, Manongi R. Quality of neonatal healthcare in Kilimanjaro region, northeast Tanzania: learning from mothers' experiences. BMC Pediatr 2013; 13:68. [PMID: 23642257 PMCID: PMC3660191 DOI: 10.1186/1471-2431-13-68] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 04/22/2013] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND With a decline of infant mortality rates, neonatal mortality rates are striking high in development countries particularly sub Saharan Africa. The toolkit for high quality neonatal services describes the principle of patient satisfaction, which we translate as mother's involvement in neonatal care and so better outcomes. The aim of the study was to assess mothers' experiences, perception and satisfaction of neonatal care in the hospitals of Kilimanjaro region of Tanzania. METHODS A cross sectional study using qualitative and quantitative approaches in 112 semi structured interviews from 14 health facilities. Open ended questions for detection of illness, care given to the baby and time spent by the health worker for care and treatment were studied. Probing of the responses was used to extract and describe findings by a mix of in-depth interview skills. Closed ended questions for the quantitative variables were used to quantify findings for statistical use. Narratives from open ended questions were coded by colours in excel sheet and themes were manually counted. RESULTS 80 mothers were interviewed from 13 peripheral facilities and 32 mothers were interviewed at a zonal referral hospital of Kilimanjaro region. 59 mothers (73.8%) in the peripheral hospitals of the region noted neonatal problems and they assisted for attaining diagnosis after a showing a concern for a request for further investigations. 11 mothers (13.8%) were able to identify the baby's diagnosis directly without any assistance, followed by 7 mothers (8.7%) who were told by a relative, and 3 mothers (3.7%) who were told of the problem by the doctor that their babies needed medical attention. 24 times mothers in the peripheral hospitals reported bad language like "I don't have time to listen to you every day and every time." 77 mothers in the periphery (90.6%) were not satisfied with the amount of time spent by the doctors in seeing their babies. CONCLUSION Mothers of the neonates play great roles in identifying the illness of the newborn. Mother's awareness of what might be needed during neonatal support strategies to improve neonatal care in both health facilities and the communities.
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Affiliation(s)
- Bernard Mbwele
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Center, P,O Box 2236, KCMC, Moshi, Tanzania.
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Upadhyay RP, Rai SK, Krishnan A. Using three delays model to understand the social factors responsible for neonatal deaths in rural Haryana, India. J Trop Pediatr 2013; 59:100-5. [PMID: 23174990 DOI: 10.1093/tropej/fms060] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To investigate causes of and contributors to newborn deaths in rural Haryana using a three delays audit approach. METHODS The study was conducted in 28 villages under the rural field practice area of the Comprehensive Rural Health Services Project, All India Institute of Medical Sciences situated in Ballabgarh, Haryana. Data were collected through house visits and analysed using the three delays model. RESULTS Of the 50 newborn deaths investigated, 44% occurred within the first 24 h after birth. The leading causes of death were pre-term/low birthweight (32%), birth asphyxia (28%) and neonatal sepsis (14%). Major contributing delays to neonatal death were caretaker's delay in deciding to seek care (44%, 22/50) and delay in reaching a health care facility, i.e. the transport delay (34%, 17/50). CONCLUSIONS Household and transport-related delays were the major contributors to newborn deaths, and efforts to improve newborn survival need to address both concurrently.
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Affiliation(s)
- Ravi Prakash Upadhyay
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
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Samuelsen H, Tersbøl BP, Mbuyita SS. Do health systems delay the treatment of poor children? A qualitative study of child deaths in rural Tanzania. BMC Health Serv Res 2013; 13:67. [PMID: 23421705 PMCID: PMC3598234 DOI: 10.1186/1472-6963-13-67] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 02/15/2013] [Indexed: 12/01/2022] Open
Abstract
Background Child mortality remains one of the major public-health problems in Tanzania. Delays in receiving and accessing adequate care contribute to these high rates. The literature on public health often focuses on the role of mothers in delaying treatment, suggesting that they contact the health system too late and that they prefer to treat their children at home, a perspective often echoed by health workers. Using the three-delay methodology, this study focus on the third phase of the model, exploring the delays experienced in receiving adequate care when mothers with a sick child contact a health-care facility. The overall objective is to analyse specific structural factors embedded in everyday practices at health facilities in a district in Tanzania which cause delays in the treatment of poor children and to discuss possible changes to institutions and social technologies. Methods The study is based on qualitative fieldwork, including in-depth interviews with sixteen mothers who have lost a child, case studies in which patients were followed through the health system, and observations of more than a hundred consultations at all three levels of the health-care system. Data analysis took the form of thematic analysis. Results Focusing on the third phase of the three-delay model, four main obstacles have been identified: confusions over payment, inadequate referral systems, the inefficient organization of health services and the culture of communication. These impediments strike the poorest segment of the mothers particularly hard. It is argued that these delaying factors function as ‘technologies of social exclusion’, as they are embedded in the everyday practices of the health facilities in systematic ways. Conclusion The interviews, case studies and observations show that it is especially families with low social and cultural capital that experience delays after having contacted the health-care system. Reductions of the various types of uncertainty concerning payment, improved referral practices and improved communication between health staff and patients would reduce some of the delays within health facilities, which might feedback positively into the other two phases of delay.
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Affiliation(s)
- Helle Samuelsen
- Department of Anthropology, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, DK 1353, Denmark.
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Cavallaro FL, Marchant TJ. Responsiveness of emergency obstetric care systems in low- and middle-income countries: a critical review of the "third delay". Acta Obstet Gynecol Scand 2013; 92:496-507. [PMID: 23278232 DOI: 10.1111/aogs.12071] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 12/06/2012] [Indexed: 11/29/2022]
Abstract
We reviewed the evidence on the duration, causes and effects of delays in providing emergency obstetric care to women attending health facilities (the third delay) in low- and middle-income countries. We performed a critical literature review using terms related to obstetric care, birth outcome, delays and developing countries. A manual search of reference lists of key articles was also performed. 69 studies met the inclusion criteria. Most studies reported long delays in providing care, and the mean waiting time for women admitted with complications was as much as 24 h before treatment. The three most cited barriers to providing timely care were shortage of treatment materials, surgery facilities and qualified staff. Existing evidence is insufficient to estimate the effect of delays on birth outcomes. Delays in providing emergency obstetric care seem common in resource-constrained settings but further research is necessary to determine the effect of the third delay on birth outcomes.
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Affiliation(s)
- Francesca L Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
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Alvesson HM, Lindelow M, Khanthaphat B, Laflamme L. Shaping healthcare-seeking processes during fatal illness in resource-poor settings. A study in Lao PDR. BMC Health Serv Res 2012; 12:477. [PMID: 23259434 PMCID: PMC3543714 DOI: 10.1186/1472-6963-12-477] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 12/18/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are profound social meanings attached to bearing children that affect the experience of losing a child, which is akin to the loss of a mother in the household. The objective of this study is to comprehend the broader processes that shape household healthcare-seeking during fatal illness episodes or reproductive health emergencies in resource-poor communities. METHODS The study was conducted in six purposively selected poor, rural communities in Lao PDR, located in two districts that represent communities with different access to health facilities and contain diverse ethnic groups. Households having experienced fatal cases were first identified in focus group discussions with community members, which lead to the identification of 26 deaths in eleven households through caregiver and spouse interviews. The interviews used an open-ended anthropological approach and followed a three-delay framework. Interpretive description was used in the data analysis. RESULTS The healthcare-seeking behavior reported by caregivers revealed a broad range of providers, reflecting the mix of public, private, informal and traditional health services in Lao PDR. Most caregivers had experienced multiple constraints in healthcare-seeking prior to death. Decisions regarding care-seeking were characterized as social rather than individual actions. They were constrained by medical costs, low expectations of recovery and worries about normative expectations from healthcare workers on how patients and caregivers should behave at health facilities to qualify for treatment. Caregivers raised the difficulties in determining the severity of the state of the child/mother. Delays in reaching care related to lack of physical access and to risks associated with taking a sick family member out of the local community. Delays in receiving care were affected by the perceived low quality of care provided at the health facilities. CONCLUSIONS Care-seeking is influenced by family- and community-based relations, which are integrated parts of people's everyday life. The medical and normative responses from health providers affect the behavior of care-seekers. An anthropological approach to capture the experience of caregivers in relation to deciding, seeking and reaching care reveals the complexity and socio-cultural context surrounding maternal and child mortality and has implications for how future mortality data should be developed and interpreted.
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Affiliation(s)
- Helle M Alvesson
- Department of Public Health Sciences, Division of Global Health, Karolinska Institutet, Nobels väg 9, Stockholm, 171 77, Sweden
| | - Magnus Lindelow
- Human Development Department, The World Bank, Brazil SCN, Quadra 2, Lote A. Ed. Corporate Center, 7th andar, Brasilia, DF, 70712-900, Brazil
| | - Bouasavanh Khanthaphat
- Indochina Research Laos Ltd, IRL Building, 282/17 Phontong-Savath, PO Box 1887, Vientiane Capital, Chanthabouly District, Laos
| | - Lucie Laflamme
- Department of Public Health Sciences, Division of Global Health, Karolinska Institutet, Nobels väg 9, Stockholm, 171 77, Sweden
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Mmbaga BT, Lie RT, Olomi R, Mahande MJ, Olola O, Daltveit AK. Causes of perinatal death at a tertiary care hospital in Northern Tanzania 2000-2010: a registry based study. BMC Pregnancy Childbirth 2012. [PMID: 23199181 PMCID: PMC3533832 DOI: 10.1186/1471-2393-12-139] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Perinatal mortality reflects maternal health as well as antenatal, intrapartum and newborn care, and is an important health indicator. This study aimed at classifying causes of perinatal death in order to identify categories of potentially preventable deaths. Methods We studied a total of 1958 stillbirths and early neonatal deaths above 500 g between July 2000 and October 2010 registered in the Medical Birth Registry and neonatal registry at Kilimanjaro Christian Medical Centre (KCMC) in Northern Tanzania. The deaths were classified according to the Neonatal and Intrauterine deaths Classification according to Etiology (NICE). Results Overall perinatal mortality was 57.7/1000 (1958 out of 33 929), of which 1219 (35.9/1000) were stillbirths and 739 (21.8/1000) were early neonatal deaths. Major causes of perinatal mortality were unexplained asphyxia (n=425, 12.5/1000), obstetric complications (n=303, 8.9/1000), maternal disease (n=287, 8.5/1000), unexplained antepartum stillbirths after 37 weeks of gestation (n= 219, 6.5/1000), and unexplained antepartum stillbirths before 37 weeks of gestation (n=184, 5.4/1000). Obstructed/prolonged labour was the leading condition (251/303, 82.8%) among the obstetric complications. Preeclampsia/eclampsia was the leading cause (253/287, 88.2%) among the maternal conditions. When we excluded women who were referred for delivery at KCMC due to medical reasons (19.1% of all births and 36.0% of all deaths), perinatal mortality was reduced to 45.6/1000. This reduction was mainly due to fewer deaths from obstetric complications (from 8.9 to 2.1/1000) and maternal conditions (from 8.5 to 5.5/1000). Conclusion The distribution of causes of death in this population suggests a great potential for prevention. Early identification of mothers at risk of pregnancy complications through antenatal care screening, teaching pregnant women to recognize signs of pregnancy complications, timely access to obstetric care, monitoring of labour for fetal distress, and proper newborn resuscitation may reduce some of the categories of deaths.
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Affiliation(s)
- Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre and Kilimanjaro Christian Medical College, P,O Box 3010, Moshi, Tanzania.
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Gartland MG, Taryor VD, Norman AM, Vermund SH. Access to facility delivery and caesarean section in north-central Liberia: a cross-sectional community-based study. BMJ Open 2012; 2:e001602. [PMID: 23117566 PMCID: PMC3532996 DOI: 10.1136/bmjopen-2012-001602] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 09/07/2012] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Rural north-central Liberia has one of the world's highest maternal mortality ratios. We studied health facility birthing service utilisation and the motives of women seeking or not seeking facility-based care in north-central Liberia. DESIGN Cross-sectional community-based structured interviews and health facility medical record review. SETTING A regional hospital and the surrounding communities in rural north-central Liberia. PARTICIPANTS A convenience sample of 307 women between 15 and 49 years participated in structured interviews. 1031 deliveries performed in the regional hospital were included in the record review. PRIMARY OUTCOMES Delivery within a health facility and caesarean delivery rates were used as indicators of direct utilisation of care and as markers of availability of maternal health services. RESULTS Of 280 interview respondents with a prior childbirth, only 47 (16.8%) delivered their last child in a health facility. Women who did not use formal services cited cost, sudden labour and family tradition or religion as their principal reasons for home delivery. At the regional hospital, the caesarean delivery rate was 35.5%. CONCLUSIONS There is an enormous unmet need for maternal health services in north-central Liberia. Greater outreach and referral services as well as community-based education among women, family members and traditional midwives are vital to improve the timely utilisation of care.
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Affiliation(s)
- Matthew G Gartland
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Andy M Norman
- Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Hirose A, Borchert M, Niksear H, Alkozai AS, Gardiner J, Filippi V. The role of care-seeking delays in intrauterine fetal deaths among 'near-miss' women in Herat, Afghanistan. Paediatr Perinat Epidemiol 2012; 26:388-97. [PMID: 22882783 DOI: 10.1111/j.1365-3016.2012.01299.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Many pregnant women in resource-poor countries seek care only after developing severe complications during childbirth at home and often reach health facilities in moribund conditions. The objectives were to (i) investigate the association between care-seeking duration and fetal survival at admission; and (ii) assess the significance of care-seeking duration in relation to other determinants. METHODS Data were analysed for 266 women who were pregnant with a singleton and admitted in life-threatening conditions to the maternity ward of Herat Regional Hospital in Afghanistan from February 2007 to January 2008. Information about the women's care-seeking durations, social and financial resources, reproductive factors, household economic status and household types were collected during interviews with the women and their husbands. Information about fetal heartbeats at admission was extracted from the women's medical records. RESULTS Fifty-four per cent of the women had a decision delay lasting 3 h or more; 69% had a transport delay lasting 3 h or more. Multivariable logistic regression analyses suggest that a decision delay lasting an hour or more increased the odds of fetal death by 6.6 (95% confidence interval [CI] 1.6, 26.3) compared with a delay less than 1 h. A woman's lack of financial autonomy and a distance from her natal home increased the odds of fetal death by 3.1 [95% CI 1.1, 8.4] and 2.5 [95% CI 1.0, 6.3] respectively. CONCLUSION An integrated approach to improving fetal and maternal health from pre-pregnancy through childbirth (including increasing women's social and financial resources) is crucial particularly where senior family members act as gatekeepers to women's access to health care.
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Affiliation(s)
- Atsumi Hirose
- London School of Hygiene & Tropical Medicine, Birkbeck College, London, UK.
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Maaløe N, Bygbjerg IC, Onesmo R, Secher NJ, Sorensen BL. Disclosing doubtful indications for emergency cesarean sections in rural hospitals in Tanzania: a retrospective criterion-based audit. Acta Obstet Gynecol Scand 2012; 91:1069-76. [PMID: 22642620 DOI: 10.1111/j.1600-0412.2012.01474.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate in depth to what extent indications for emergency cesarean sections followed evidence-based audit criteria for realistic best practice. DESIGN A quality assurance analysis based on a retrospective criterion-based audit. SETTING Two rural hospitals in Tanzania. POPULATION From 2009, 400 cesarean section instances were investigated. Of these, 303 were emergency cesarean sections and therefore included. METHODS Documented indications for and management preceding the emergency cesarean sections were compared with the audit criteria. MAIN OUTCOME MEASURES Prevalence of suboptimal care. RESULTS Of the emergency sections, 26% appeared to be decided based on inappropriate indications, and in an additional 38%, the indications were unclear. Prolonged labor was the leading indication; in 36% of these, labor progressed timely and/or the membranes were still intact. In 26%, previous cesarean section was the indication, half of these with one previous section only. Fetal distress was an indication in 14%, but for 84% of these the fetal heart rate was either reassuring or not documented. For nine women, section was decided upon because of intrauterine fetal death; none had a trial of forceps/vacuum extraction or destructive surgery. CONCLUSION A considerable number of the audited emergency cesarean sections were performed on doubtful indications. In the light of the rising trend in global cesarean section rates, there seems to be a need to ensure quality of management preceding cesarean sections. This is particularly called for in rural sub-Saharan Africa where cesarean rates are still low and health risks of emergency surgery not negligible.
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Affiliation(s)
- Nanna Maaløe
- Department of International Health, Immunology, and Microbiology, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, Denmark.
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Bapat U, Alcock G, More NS, Das S, Joshi W, Osrin D. Stillbirths and newborn deaths in slum settlements in Mumbai, India: a prospective verbal autopsy study. BMC Pregnancy Childbirth 2012; 12:39. [PMID: 22646304 PMCID: PMC3405477 DOI: 10.1186/1471-2393-12-39] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 05/30/2012] [Indexed: 11/20/2022] Open
Abstract
Background Three million babies are stillborn each year and 3.6 million die in the first month of life. In India, early neonatal deaths make up four-fifths of neonatal deaths and infant mortality three-quarters of under-five mortality. Information is scarce on cause-specific perinatal and neonatal mortality in urban settings in low-income countries. We conducted verbal autopsies for stillbirths and neonatal deaths in Mumbai slum settlements. Our objectives were to classify deaths according to international cause-specific criteria and to identify major causes of delay in seeking and receiving health care for maternal and newborn health problems. Methods Over two years, 2005–2007, births and newborn deaths in 48 slum areas were identified prospectively by local informants. Verbal autopsies were collected by trained field researchers, cause of death was classified by clinicians, and family narratives were analysed to investigate delays on the pathway to mortality. Results Of 105 stillbirths, 65 were fresh (62%) and obstetric complications dominated the cause classification. Of 116 neonatal deaths, 87 were early and the major causes were intrapartum-related (28%), prematurity (23%), and severe infection (22%). Bereavement was associated with socioeconomic quintile, previous stillbirth, and number of antenatal care visits. We identified 201 individual delays in 121/187 birth narratives (65%). Overall, delays in receiving care after arrival at a health facility dominated and were mostly the result of referral from one institution to another. Most delays in seeking care were attributed to a failure to recognise symptoms of complications or their severity. Conclusions In Mumbai’s slum settlements, early neonatal deaths made up 75% of neonatal deaths and intrapartum-related complications were the greatest cause of mortality. Delays were identified in two-thirds of narratives, were predominantly related to the provision of care, and were often attributable to referrals between health providers. There is a need for clear protocols for care and transfer at each level of the health system, and an emphasis on rapid identification of problems and communication between health facilities. Trial registration ISRCTN96256793
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Affiliation(s)
- Ujwala Bapat
- Society for Nutrition, Education and Health Action (SNEHA), Urban Health Centre, Chota Sion Hospital, Dharavi, Mumbai, Maharashtra, India
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Maaløe N, Sorensen BL, Onesmo R, Secher NJ, Bygbjerg IC. Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals. BJOG 2012; 119:605-13. [PMID: 22329559 DOI: 10.1111/j.1471-0528.2012.03284.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To audit the quality of obstetric management preceding emergency caesarean sections for prolonged labour. DESIGN A quality assurance analysis of a retrospective criterion-based audit supplemented by in-depth interviews with hospital staff. SETTING Two Tanzanian rural mission hospitals. POPULATION Audit of 144 cases of women undergoing caesarean sections for prolonged labour; in addition, eight staff members were interviewed. METHODS Criteria of realistic best practice were established, and the case files were audited and compared with these. Hospital staff were interviewed about what they felt might be the causes for the audit findings. MAIN OUTCOME MEASURES Prevalence of suboptimal management and themes emerging from an analysis of the transcripts. RESULTS Suboptimal management was identified in most cases. Non-invasive interventions to potentially avoid operative delivery were inadequately used. When deciding on caesarean section, in 26% of the cases labour was not prolonged, and in 16% the membranes were still intact. Of the women with genuine prolonged labour, caesarean sections were performed with a fully dilated cervix in 36% of the cases. Vacuum extraction was not considered. Amongst the hospital staff interviewed, the awareness of evidence-based guidelines was poor. Word of mouth, personal experience, and fear, especially of HIV transmission, influenced management decisions. CONCLUSION The lack of use and awareness of evidence-based guidelines led to misinterpretation of clinical signs, fear of simple interventions, and an excessive rate of emergency caesarean sections.
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Affiliation(s)
- N Maaløe
- Department of International Health, Immunology, and Microbiology, University of Copenhagen, Copenhagen, Denmark.
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Wellhoner M, Lee AC, Deutsch K, Wiebenga M, Freytsis M, Drogha S, Dongdrup P, Lhamo K, Tsering O, Tse Yong-Jee J, Khandro D, Mullany LC, Weingrad L. Maternal and child health in yushu, qinghai province, china. Int J Equity Health 2011; 10:42. [PMID: 21970463 PMCID: PMC3213196 DOI: 10.1186/1475-9276-10-42] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 10/04/2011] [Indexed: 11/12/2022] Open
Abstract
Introduction Surmang, Qinghai Province is a rural nomadic Tibetan region in western China recently devastated by the 2010 Yushu earthquake; little information is available on access and coverage of maternal and child health services. Methods A cross-sectional household survey was conducted in August 2004. 402 women of reproductive age (15-50) were interviewed regarding their pregnancy history, access to and utilization of health care, and infant and child health care practices. Results Women's access to education was low at 15% for any formal schooling; adult female literacy was <20%. One third of women received any antenatal care during their last pregnancy. Institutional delivery and skilled birth attendance were <1%, and there were no reported cesarean deliveries. Birth was commonly attended by a female relative, and 8% of women delivered alone. Use of unsterilized instrument to cut the umbilical cord was nearly universal (94%), while coverage for tetanus toxoid immunization was only 14%. Traditional Tibetan healers were frequently sought for problems during pregnancy (70%), the postpartum period (87%), and for childhood illnesses (74%). Western medicine (61%) was preferred over Tibetan medicine (9%) for preventive antenatal care. The average time to reach a health facility was 4.3 hours. Postpartum infectious morbidity appeared to be high, but only 3% of women with postpartum problems received western medical care. 64% of recently pregnant women reported that they were very worried about dying in childbirth. The community reported 3 maternal deaths and 103 live births in the 19 months prior to the survey. Conclusions While China is on track to achieve national Millennium Development Goal targets for maternal and child health, women and children in Surmang suffer from substantial health inequities in access to antenatal, skilled birth and postpartum care. Institutional delivery, skilled attendance and cesarean delivery are virtually inaccessible, and consequently maternal and infant morbidity and mortality are likely high. Urgent action is needed to improve access to maternal, neonatal and child health care in these marginalized populations. The reconstruction after the recent earthquake provides a unique opportunity to link this population with the health system.
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Jammeh A, Sundby J, Vangen S. Barriers to emergency obstetric care services in perinatal deaths in rural gambia: a qualitative in-depth interview study. ISRN OBSTETRICS AND GYNECOLOGY 2011; 2011:981096. [PMID: 21766039 PMCID: PMC3135215 DOI: 10.5402/2011/981096] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 05/07/2011] [Indexed: 11/23/2022]
Abstract
Objective. The Gambia has one of the world's highest perinatal mortality rates. We explored barriers of timely access to emergency obstetric care services resulting in perinatal deaths and in survivors of severe obstetric complications in rural Gambia. Method. We applied the “three delays” model as a framework for assessing contributing factors to perinatal deaths and obstetric complications. Qualitative in-depth interviews were conducted with 20 survivors of severe obstetric complications at home settings within three to four weeks after hospital discharge. Family members and traditional birth attendants were also interviewed. The interviews were translated into English and transcribed verbatim. We used content analysis to identify barriers of care. Results. Transport/cost-related delays are the major contributors of perinatal deaths in this study. A delay in recognising danger signs of pregnancy/labour or decision to seek care outside the home was the second important contributor of perinatal deaths. Decision to seek care may be timely, but impaired access precluded utilization of EmOC services. Obtaining blood for transfusion was also identified as a deterrent to appropriate care. Conclusion. Delays in accessing EmOC are critical in perinatal deaths. Thus, timely availability of emergency transport services and prompt decision-making are warranted for improved perinatal outcomes in rural Gambia.
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Affiliation(s)
- Abdou Jammeh
- Section for International Health, Department of General Practice and Community of Medicine, Institute of Health and Society, University of Oslo, P.O. BOX 1130, Blindern, 0318 Oslo, Norway
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Premji SS, Kanji Z. Global Perspectives on the Neonatal Intensive Care Unit: Vulnerable Babies of the World. ACTA ACUST UNITED AC 2011. [DOI: 10.1053/j.nainr.2011.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Waiswa P, Kallander K, Peterson S, Tomson G, Pariyo GW. Using the three delays model to understand why newborn babies die in eastern Uganda. Trop Med Int Health 2010; 15:964-72. [PMID: 20636527 DOI: 10.1111/j.1365-3156.2010.02557.x] [Citation(s) in RCA: 182] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate causes of and contributors to newborn deaths in eastern Uganda using a three delays audit approach. Methods Data collected on 64 neonatal deaths from a demographic surveillance site were coded for causes of deaths using a hierarchical model and analysed using a modified three delays model to determine contributing delays. A survey was conducted in 16 health facilities to determine capacity for newborn care. RESULTS Of the newborn babies, 33% died in a hospital/health centre, 13% in a private clinic and 54% died away from a health facility. 47% of the deaths occurred on the day of birth and 78% in the first week. Major contributing delays to newborn death were caretaker delay in problem recognition or in deciding to seek care (50%, 32/64); delay to receive quality care at a health facility (30%; 19/64); and transport delay (20%; 13/64). The median time to seeking care outside the home was 3 days from onset of illness (IQR 1-6). The leading causes of death were sepsis or pneumonia (31%), birth asphyxia (30%) and preterm birth (25%). Health facilities did not have capacity for newborn care, and health workers had correct knowledge on only 31% of the survey questions related to newborn care. CONCLUSIONS Household and health facility-related delays were the major contributors to newborn deaths, and efforts to improve newborn survival need to address both concurrently. Understanding why newborn babies die can be improved by using the three delays model, originally developed for understanding maternal death.
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Affiliation(s)
- Peter Waiswa
- Division of Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
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Pattinson R, Kerber K, Waiswa P, Day LT, Mussell F, Asiruddin SK, Blencowe H, Lawn JE. Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries. Int J Gynaecol Obstet 2010; 107 Suppl 1:S113-21, S121-2. [PMID: 19815206 DOI: 10.1016/j.ijgo.2009.07.011] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In high-income countries, national mortality audits are associated with improved quality of care, but there has been no previous systematic review of perinatal audit in low- and middle-income settings. OBJECTIVES To present a systematic review of facility-based perinatal mortality audit in low- and middle-income countries, and review information regarding community audit. RESULTS Ten low-quality evaluations with mortality outcome data were identified. Meta-analysis of 7 before-and-after studies indicated a reduction in perinatal mortality of 30% (95% confidence interval, 21%-38%) after introduction of perinatal audit. The consistency of effect suggests that audit may be a useful tool for decreasing perinatal mortality rates in facilities and improving quality of care, although none of these evaluations were large scale. Few of the identified studies reported intrapartum-related perinatal outcomes. Novel experience of community audit and social autopsy is described, but data reporting mortality outcome effect are lacking. There are few examples of wide-scale, sustained perinatal audit in low-income settings. Two national cases studies (South Africa and Bangladesh) are presented. Programmatic decision points, challenges, and key factors for national or wide scale-up of sustained perinatal mortality audit are discussed. As a minimum standard, facilities should track intrapartum stillbirth and pre-discharge intrapartum-related neonatal mortality rates. CONCLUSION The effect of perinatal audit depends on the ability to close the audit loop; without effectively implementing the solutions to the problems identified, audit alone cannot improve quality of care.
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Affiliation(s)
- Robert Pattinson
- MRC Maternal and Infant Health Care Strategies Research Unit, University of Pretoria, Pretoria, South Africa.
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Lee ACC, Lawn JE, Cousens S, Kumar V, Osrin D, Bhutta ZA, Wall SN, Nandakumar AK, Syed U, Darmstadt GL. Linking families and facilities for care at birth: what works to avert intrapartum-related deaths? Int J Gynaecol Obstet 2010; 107 Suppl 1:S65-85, S86-8. [PMID: 19815201 DOI: 10.1016/j.ijgo.2009.07.012] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delays in receiving effective care during labor and at birth may be fatal for the mother and fetus, contributing to 2 million annual intrapartum stillbirths and intrapartum-related neonatal deaths each year. OBJECTIVE We present a systematic review of strategies to link families and facilities, including community mobilization, financial incentives, emergency referral and transport systems, prenatal risk screening, and maternity waiting homes. RESULTS There is moderate quality evidence that community mobilization with high levels of community engagement can increase institutional births and significantly reduce perinatal and early neonatal mortality. Meta-analysis showed a doubling of skilled birth attendance and a 36% reduction in early neonatal mortality. However, no data are available on intrapartum-specific outcomes. Evidence is limited, but promising, that financial incentive schemes and community referral/transport systems may increase rates of skilled birth attendance and emergency obstetric care utilization; however, impact on mortality is unknown. Current evidence for maternity waiting homes and risk screening is low quality. CONCLUSIONS Empowering communities is an important strategy to reduce the large burden of intrapartum complications. Innovations are needed to bring the poor closer to obstetric care, such as financial incentives and cell phone technology. New questions need to be asked of "old" strategies such as risk screening and maternity waiting homes. The effect of all of these strategies on maternal and perinatal mortality, particularly intrapartum-related outcomes, requires further evaluation.
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Affiliation(s)
- Anne C C Lee
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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‘MAYBE IT WAS HER FATE AND MAYBE SHE RAN OUT OF BLOOD’: FINAL CAREGIVERS' PERSPECTIVES ON ACCESS TO CARE IN OBSTETRIC EMERGENCIES IN RURAL INDONESIA. J Biosoc Sci 2009; 42:213-41. [DOI: 10.1017/s0021932009990496] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SummaryMaternal mortality persists in low-income settings despite preventability with skilled birth attendance and emergency obstetric care. Poor access limits the effectiveness of life-saving interventions and is typical of maternal health care in low-income settings. This paper examines access to care in obstetric emergencies from the perspectives of service users, using established and contemporary theoretical frameworks of access and a routine health surveillance method. The implications for health planning are also considered. The final caregivers of 104 women who died during pregnancy or childbirth were interviewed in two rural districts in Indonesia using an adapted verbal autopsy. Qualitative analysis revealed social and economic barriers to access and barriers that arose from the health system itself. Health insurance for the poor was highly problematic. For providers, incomplete reimbursements, and low public pay, acted as disincentives to treat the poor. For users, the schemes were poorly socialized and understood, complicated to use and led to lower quality care. Services, staff, transport, equipment and supplies were also generally unavailable or unaffordable. The multiple barriers to access conferred a cumulative disadvantage that culminated in exclusion. This was reflected in expressions of powerlessness and fatalism regarding the deaths. The analysis suggests that conceiving of access as a structurally determined, complex and dynamic process, and as a reciprocally maintained phenomenon of disadvantaged groups, may provide useful explanatory concepts for health planning. Health planning from this perspective may help to avoid perpetuating exclusion on social and economic grounds, by health systems and services, and help foster a sense of control at the micro-level, among peoples' feelings and behaviours regarding their health. Verbal autopsy surveys provide an opportunity to routinely collect
information on the exclusory mechanisms of health systems, important information for equitable health planning.
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80
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van den Akker T, Mwagomba B, Irlam J, van Roosmalen J. Using audits to reduce the incidence of uterine rupture in a Malawian district hospital. Int J Gynaecol Obstet 2009; 107:289-94. [PMID: 19846089 DOI: 10.1016/j.ijgo.2009.09.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To improve obstetric care and reduce the incidence of uterine rupture through the use of audits. METHODS Data were collected from medical records and from questioning women who sustained uterine rupture over a 12-month period in Thyolo District Hospital, Malawi. Audit sessions were performed every 2-3 weeks for the first 3 months with relevant members of the hospital staff, after which an extended audit was held with input from two external expert obstetricians. Cases were also audited by the principal investigator for delays in referral, diagnosis, and treatment. RESULTS Thirty-five cases of uterine rupture were diagnosed at the facility during the study period. Sixteen ruptures were diagnosed during the first 3 months, an incidence of 19.2 per 1000 deliveries. Following audit and implementation of recommendations, the incidence of uterine rupture decreased by 68% (OR 0.32; 95% CI, 0.16-0.63) to 6.1 per 1000 deliveries over the next 9 months. The overall case fatality rate was 11.4%, and the perinatal mortality rate was 829 per 1000 live births. CONCLUSIONS Audit is an inexpensive, appropriate, and effective intervention to improve the quality of facility-based maternal care and decrease the incidence of uterine rupture in low-resource settings. Ensuring constructive self-criticism, continuous professional learning, and good participation by district health managers in audit sessions may be important requirements for their success.
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81
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Reducing intrapartum-related deaths and disability: Can the health system deliver? Int J Gynaecol Obstet 2009; 107 Suppl 1:S123-40, S140-2. [DOI: 10.1016/j.ijgo.2009.07.021] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kidanto HL, Mogren I, van Roosmalen J, Thomas AN, Massawe SN, Nystrom L, Lindmark G. Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. BMC Pregnancy Childbirth 2009; 9:45. [PMID: 19765312 PMCID: PMC2754979 DOI: 10.1186/1471-2393-9-45] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 09/19/2009] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Perinatal death is a devastating experience for the mother and of concern in clinical practice. Regular perinatal audit may identify suboptimal care related to perinatal deaths and thus appropriate measures for its reduction. The aim of this study was to perform a qualitative perinatal audit of intrapartum and early neonatal deaths and propose means of reducing the perinatal mortality rate (PMR). METHODS From 1st August, 2007 to 31st December, 2007 we conducted an audit of perinatal deaths (n = 133) with birth weight 1500 g or more at Muhimbili National Hospital (MNH). The audit was done by three obstetricians, two external and one internal auditors. Each auditor independently evaluated the cases narratives. Suboptimal factors were identified in the antepartum, intrapartum and early neonatal period and classified into three levels of delay (community, infrastructure and health care). The contribution of each suboptimal factor to adverse perinatal outcome was identified and the case graded according to possible avoidability. Degree of agreement between auditors was assessed by the kappa coefficient. RESULTS The PMR was 92 per 1000 total births. Suboptimal factors were identified in 80% of audited cases and half of suboptimal factors were found to be the likely cause of adverse perinatal outcome and were preventable. Poor foetal heart monitoring during labour was indirectly associated with over 40% of perinatal death. There was a poor to fair agreement between external and internal auditors. CONCLUSION There are significant areas of care that need improvement. Poor monitoring during labour was a major cause of avoidable perinatal mortality. This type of audit was a good starting point for quality assurance at MNH. Regular perinatal audits to identify avoidable causes of perinatal deaths with feed back to the staff may be a useful strategy to reduce perinatal mortality.
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Affiliation(s)
- Hussein L Kidanto
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences, Umeå University, Umeå, Sweden
| | - Ingrid Mogren
- Department of Clinical Science, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden
| | - Jos van Roosmalen
- Department of Obstetrics, Leiden University Medical Centre and Section of Health care and Culture, VU University Medical Centre, Amsterdam, The Netherlands
| | - Angela N Thomas
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Siriel N Massawe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Lennarth Nystrom
- Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences, Umeå University, Umeå, Sweden
| | - Gunilla Lindmark
- Department of Women's and Children's Health, Academic Hospital, Uppsala, Sweden
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