Incidence of severe maternal outcomes following armed conflict in East Gojjam zone, Amhara region, Ethiopia: using the sub-Saharan Africa maternal near-miss criteria

Background

Severe maternal outcome (SMO) encompasses women who survive life-threatening conditions either by chance or due to treatment quality, or who die. This concept assumes that severe maternal morbidity predicts mortality risk, enabling the analysis of risk factors for life-threatening outcomes and improving our understanding on the causes of maternal death. This study aims to determine the incidence of SMO and its leading causes in East Gojjam during a period of regional conflict.

Methods

A prospective follow-up study was conducted at Debre Markos Comprehensive Specialized Hospital in East Gojjam from July 1, 2023, to February 30, 2024. The study included 367 women admitted with potentially life-threatening conditions, including 8 maternal deaths, using sub-Saharan Africa (SSA) and WHO Maternal Near-Miss (MNM) criteria. Data were entered into Epi Data v.4.6 and analyzed using SPSS v.27. The WHO MNM approach assessed SMO indicators and maternal health care quality were utilized.

Results

During the eight-month period, there were 3,167 live births, 359 potentially life-threatening conditions (PLTC), and 188 SMO cases (180 MNM and 8 maternal deaths). The SMO ratio was 59.4 per 1,000 live births (95% CI: 51, 68 per 1,000 live births). The MNM to mortality ratio, mortality index, and maternal mortality ratio were 22.5:1, 4.2%, and 252.6 per 100,000 live births, respectively. Over 80% of women with SMO showed evidence of organ dysfunction upon arrival or within 12 h of hospitalization. The leading causes of SMO were hypertensive disorders of pregnancy (HDP) and obstetric hemorrhage, including uterine rupture, with uterine rupture contributing to half of the maternal deaths.

Conclusion

This study found that the incidence of SMO was comparable to that reported in most other studies. HDP was the primary cause of SMO, followed by obstetrical hemorrhage, consistent with other studies in Ethiopia. Uterine rupture was identified as the leading cause of maternal death. As this study was conducted in a single institution and in the period of severe armed conflict, it may not fully capture the range of maternal health issues across populations with varying healthcare access and socio-economic backgrounds. Caution should be exercised when generalizing these findings to the wider population.

Assessment of neonatal referral infrastructure and clinical characteristics of referred neonates in three first referral hospitals in Nairobi County, Kenya

Background

One in five newborns in Nairobi County, Kenya, may require inpatient neonatal care. We sought to examine referrals to and from three busy first-level referral public hospitals in Nairobi and what infrastructure and systems are available to support neonatal transport from these first-referral level hospitals to the main tertiary care center.

Methods

Patient-level data of newborns over 12 months were retrospectively extracted from routinely collected patient data and examined to characterize those referred into and out of three newborn units in the study hospitals. Structural assessments using a checklist completed during hospital visits were used to describe hospitals' readiness to support newborn referral and transport.

Results

Five percent (398/7720) of the cohort studied were either referrals into study hospitals (68%, 272/398) or referrals out (32%, 126/398). Among 397 (99%) and 268 (67%) with sex and gestation documented respectively, 63% (251) were male and 44% (118) were preterm infants (<37 weeks). Among those referred in, 26% (69/272) died and 2.6% (7/272) were further referred to a tertiary-care newborn unit. Prematurity (39%) and birth asphyxia (29%) were the main in-referral reasons from 38 different health facilities, with specialist reviews (34%) predominant for out-referrals to a tertiary center. Diverse transport methods were used for referrals to study hospitals including private and public ambulances, vehicles, and guardian's arms while onward referrals to the tertiary center were done by hospital ambulances. Drugs and medical supplies required for stabilization were well available at the study sites, however, only oxygen nasal cannula, nasal prongs, and face masks were available in ambulance of hospital 3.

Conclusion

There is a need to develop, equip and maintain a high-quality referral and newborn transport system that can support the continuum of newborn care across referral care pathways into and from first-referral level hospitals.

Strengthening Kampala's Urban Referral System for Maternal and Newborn Care Through Establishment of an Emergency Call and Dispatch Center

INTRODUCTION

Most pregnant women living in urban slum communities in Uganda deliver at public health centers that are not equipped to provide emergency obstetric and newborn care. When obstetric emergencies occur, pregnant women are referred to a higher-level facility and are responsible for arranging and paying for their own transport. The Kampala Slum Maternal Newborn (MaNe) project developed and tested an emergency call and ambulance dispatch center and a mobile application to request, deploy, and track ambulances. We describe the development of these 2 interventions and findings on the feasibility, acceptability, and sustainability of the interventions.

METHODS

MaNe conducted a mixed-method feasibility study that included an assessment of the acceptability and demand of the interventions. In-depth interviews (N=26) were conducted with facility proprietors, health providers, ambulance drivers, Kampala Capital City Authority officers, and community members to understand the successes and challenges of establishing the call center and developing the mobile application. Thematic content analysis was done. Quantitative data from the call center dispatch logs were analyzed descriptively to complement the qualitative findings.

FINDINGS

Between April 2020 and June 2021, 10,183 calls were made to the emergency call and dispatch center. Of these, 25% were related to maternal and newborn health emergencies and 14% were COVID-19 related. An ambulance was dispatched to transfer or evacuate a patient in 35% of the calls. Participants acknowledged that the call center and mobile application allowed for efficient communication, coordination, and information flow between health facilities. Supportive district leadership facilitated the establishment of the call center and has taken over the operating costs of the center.

CONCLUSION

The call center and referral application improved the coordination of drivers and ambulances and allowed facilities to prepare for and treat cases more efficiently.

Networks of Care: An Approach to Improving Maternal and Newborn Health

The Networks of Care approach has the potential to harmonize existing strategies and optimize health systems functions for maternal and newborn health, thereby strengthening the quality of care and ultimately improving outcomes.

KK, Horo M, Shumayla S, Mehra S. Generating evidence on screening, diagnosis and management of non-communicable diseases during pregnancy; a scoping review of current gap and practice in India with a comparison of Asian context

BACKGROUND

Children born to high-risk pregnancies are more likely to experience adverse health outcomes later in life. As estimated, 15% of all pregnancies are at risk of various life-threatening conditions leading to adverse maternal and foetal outcomes. Millennium Development Goal resulted in the global reduction of maternal death from 390,000 to 275000 in 1990-2015). Similarly, to keep this momentum, the current United Nations Sustainable Development Goal (SDG: 3.1) aims at reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030, and this can be achieved by addressing high-risk pregnancy contributing to significant mortality and morbidity. In India, gestational diabetes, gestational hypertension, and gestational hypothyroidism were identified as factors contributing to the high-risk pregnancy. This review summarises the commonly used approach for screening, diagnosis, and management of these conditions in the Asian population. It draws a comparison with the current protocols and guidelines in the Indian setting.

METHODS

Electronic search in PubMed and Google Scholar, reference snowballing, and review of current guidelines and protocols were done between January 2010 to October 2019. Published studies reporting Screening, diagnosis, and management of these conditions were included. Articles selected were then screened, appraised for quality, extract relevant data, and synthesised.

RESULTS

Screening, diagnosis, and management of these three conditions vary and no single universally accepted criteria for diagnosis and management exist to date. In India, national guidelines available have not been evaluated for feasibility of implementation at the community level. There are no national guidelines for PIH diagnosis and management despite the increasing burden and contribution to maternal and perinatal morbidity and mortality. Criteria for diagnosis and management of gestational diabetes, gestational hypertension, and gestational hypothyroidism varies but overall early screening for predicting risk, as reported from majority of the articles, were effective in minimizing maternal and foetal outcome.

CONCLUSION

Existing National guidelines for Screening, Diagnosis, and Management of Gestational Diabetes Mellitus (2018) and Gestational Hypothyroidism (2014) need to be contextualized and modified based on the need of the local population for effective treatment. Findings from this review show that early screening for predicting risk to be an effective preventive strategy. However, reports related to a definitive diagnosis and medical management were heterogeneous.

Developing a Common Understanding of Networks of Care through a Scoping Study

The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multi-method scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low- and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.

Healthcare providers' perception of the referral system in maternal care facilities in Aceh, Indonesia: a cross-sectional study

OBJECTIVES

Our study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia.

DESIGN

With a cross-sectional approach, two sets of surveys were administered during September to October 2016 in 32 sampling units of our study. We also collected referral data in the form of the frequency of ingoing and outgoing referral cases per facility.

SETTING

In three districts, Aceh Besar, Banda Aceh and Bireuen, a total of 32 facilities including hospitals, community health centres, and private midwife clinics that met the criteria of providing at least basic emergency obstetric and neonatal care (BEonC) were covered.

PARTICIPANTS

Across the 32 healthcare centres, 149 members of staff (mainly midwives) agreed to participate in our surveys.

PRIMARY AND SECONDARY OUTCOME MEASURES

The first survey consisted of 65 items focusing on organisational measures as well as case numbers for example, patient counts, mortality rate and complications. The second survey with 68 items asked healthcare providers about a range of factors including attitudes towards the referral process in their facility and potential barriers to a well-functioning system in their district.

RESULTS

Overall, mothers'/families' consent as well as the complex administration process were found to be the main barriers (36% and 12%, respectively). Healthcare providers noted that information about other facilities has the biggest room for improvement (37%) rather than transport, timely referral of mothers and babies, or the availability of referral facilities.

CONCLUSIONS

The largest barrier perceived by healthcare providers in our study was noted to be family consent and administrative burden. Moreover, lack of information about the referral system itself and other facilities seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.

Presence of doctors and obstetrician/gynecologists for patients with maternal complications in hospitals in six provinces of Indonesia

OBJECTIVE

To describe doctors' and specialist physicians' availability to manage obstetric complications in hospitals in six provinces of Indonesia.

METHODS

Data from a nonrandomized, quasi-experimental pre-post evaluation study were used to describe the distribution of providers by each cadre of worker and assess the availability of doctors and obstetrician/gynecologists (ob/gyns) for consultations for women experiencing postpartum hemorrhage or pre-eclampsia/eclampsia, disaggregated by hospital type, province, referral status, and by time of day of provider consultation.

RESULTS

Among hospitals that should have comprehensive emergency obstetric and newborn care (CEmONC) services available 24 hours a day, 7 days a week, many did not have a doctor available to manage obstetric complications as they presented, despite there being an average of seven ob/gyns and four doctors registered for service across all facilities. Slightly over 50% of obstetric emergency cases admitted with postpartum hemorrhage and severe pre-eclampsia/eclampsia did not receive a consultation from an ob/gyn. Among the patients who received consultations, about 70% received consultations by phone or SMS.

CONCLUSION

Findings from this study indicate that persistent issues of maldistribution of maternal and newborn specialists and high absence rates of both doctors and ob/gyns at CEmONC hospitals during obstetric emergencies undermines Indonesia's efforts to reduce high maternal mortality rates.