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Mwene-Batu P, Ndokabilya E, Lembebu JC, Ngaboyeka G, Mary M, Tappis H, Dramaix M, Chimanuka C, Chiribagula C, Bigirinama R, Hermans MP, Bisimwa G. Maternal mortality in Eastern Democratic Republic of Congo: a 10-year multi-zonal institutional death review. BMC Public Health 2024; 24:2280. [PMID: 39174933 PMCID: PMC11340148 DOI: 10.1186/s12889-024-19804-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 08/14/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Maternal mortality (MM) remains a real scourge that hits hardest in the poorest regions of the world, particularly those affected by conflict. However, despite this worrying reality, few studies have been conducted about MM ratio in the Democratic Republic of Congo (DRC). The study aimed to describe the trends as well as the epidemiological profile and causes of reported institutional maternal deaths between 2013 and 2022 in Eastern DRC. METHODS A retrospective descriptive study was conducted between March 2023 and August 2023 in eight Health Zones (HZ), five in South Kivu Province (Mwana, Minova, Miti-Murhesa, Kamituga and Idjwi) and three in North Kivu Province (Kirotshe, Karisimbi and Kayna) in the eastern region of the DRC. Our study covers 242 health facilities: 168 health centers (HC), 16 referral health centers (RHCs),50 referral hospitals (RH) and 8 general referral hospitals (GRHs). Data from registers and medical records of maternal deaths recorded in these zones from 2013-2022 were extracted along with information on the number of deliveries and live births. Sociodemographic, clinical parameters, blood and ultrasound tests and suspected causes of death between provinces were assessed. RESULTS In total, we obtained 177 files on deceased women. Of these, 143 (80.8%) were retained for the present study, including 75 in the 3 HZs of North Kivu and 68 in the 5 HZs of South Kivu. From 2013 to 2022, study sites experienced two significant drops in maternal mortality ratio (MMR) (in 2015 and 2018), and a spike in 2016-2017. Nonetheless, the combined MMR (across study sites) started and ended the 10-year study period at approximately the same level (53 and 57 deaths per 100,000 live births in 2013 and 2022 respectively). Overall, 62,6% of the deaths were reported from secondary hospital. Most deaths were of married women in their thirties (93.5%). Almost half (47.8%) had not completed four antenatal consultations. The main direct causes of death were, in decreasing order of frequency: post-partum haemorrhage (55.2%), uterine rupture (14.0), hypertensive disorders (8.4%), abortion (7.7%) puerperal infections (2.8%) and placental abruption (0.7%). When comparing among provinces, reported abortion-related maternal mortality (14.1% vs 0%) was more frequent in North Kivu than in South Kivu. CONCLUSION This study imperatively highlights the need for targeted interventions to reduce maternal mortality. By emphasizing the crucial importance of antenatal consultations, intrapartum/immediate post-partum care and quality of care, significant progress can be made in guaranteeing maternal health and reducing many avoidable deaths.
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Affiliation(s)
- Pacifique Mwene-Batu
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu (ERSP-UCB), Bukavu, Democratic Republic of the Congo.
- Faculté de Médecine, Université de Kaziba, Kaziba, Democratic Republic of the Congo.
- Hôpital Provincial Général de Référence de Bukavu (HPGRB), Bukavu, Democratic Republic of the Congo.
| | - Eustache Ndokabilya
- Direction du Développement Et de La Coopération Suisse (DDC), Bukavu, Democratic Republic of the Congo
| | - Jean Corneille Lembebu
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu (ERSP-UCB), Bukavu, Democratic Republic of the Congo
| | - Gaylord Ngaboyeka
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu (ERSP-UCB), Bukavu, Democratic Republic of the Congo
| | - Meighan Mary
- Johns Hopkins Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Hannah Tappis
- Johns Hopkins Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Michelle Dramaix
- Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
| | - Christine Chimanuka
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu (ERSP-UCB), Bukavu, Democratic Republic of the Congo
| | - Christian Chiribagula
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu (ERSP-UCB), Bukavu, Democratic Republic of the Congo
| | - Rosine Bigirinama
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu (ERSP-UCB), Bukavu, Democratic Republic of the Congo
| | - Michel P Hermans
- Division of Endocrinology & Nutrition, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Ghislain Bisimwa
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu (ERSP-UCB), Bukavu, Democratic Republic of the Congo
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Tesfay N, Tariku R, Zenebe A, Habtetsion M, Woldeyohannes F. Place of death and associated factors among reviewed maternal deaths in Ethiopia: a generalised structural equation modelling. BMJ Open 2023; 13:e060933. [PMID: 36697051 PMCID: PMC9884926 DOI: 10.1136/bmjopen-2022-060933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE The study aims to determine the magnitude and factors that affect maternal death in different settings. DESIGN, SETTING AND ANALYSIS A review of national maternal death surveillance data was conducted. The data were obtained through medical record review and verbal autopsies of each death. Generalised structural equation modelling was employed to simultaneously examine the relationships among exogenous, mediating (urban/rural residence) and endogenous variables. OUTCOME Magnitude and factors related to the location of maternal death. PARTICIPANTS A total of 4316 maternal deaths were reviewed from 2013 to 2020. RESULTS Facility death constitutes 69.0% of maternal deaths in the reporting period followed by home death and death while in transit, each contributing to 17.0% and 13.6% of maternal deaths, respectively. Educational status has a positive direct effect on death occurring at home (β=0.42, 95% CI 0.22 to 0.66), obstetric haemorrhage has a direct positive effect on deaths occurring at home (β=0.41, 95% CI 0.04 to 0.80) and death in transit (β=0.68, 95% CI 0.48 to 0.87), while it has a direct negative effect on death occurring at a health facility (β=-0.60, 95% CI -0.77 to -0.44). Moreover, unanticipated management of complication has a positive direct (β=0.99, 95% CI 0.34 to 1.63), indirect (β=0.05, 95% CI 0.04 to 0.07) and total (β=1.04, 95% CI 0.38 to 1.70) effect on facility death. Residence is a mediator variable and is associated with all places of death. It has a connection with facility death (β=-0.70, 95% CI -0.95 to -0.46), death during transit (β=0.51, 95% CI 0.20 to 0.83) and death at home (β=0.85, 95% CI 0.54 to 1.17). CONCLUSION Almost 7 in 10 maternal deaths occurred at the health facility. Sociodemographic factors, medical causes of death and non-medical causes of death mediated by residence were factors associated with the place of death. Thus, factors related to the place of death should be considered as an area of intervention to mitigate preventable maternal death that occurred in different settings.
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Affiliation(s)
- Neamin Tesfay
- Centre of Public Health Emergency Management, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Rozina Tariku
- Centre of Public Health Emergency Management, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Alemu Zenebe
- Centre of Public Health Emergency Management, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Medhanye Habtetsion
- Centre of Public Health Emergency Management, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Fitsum Woldeyohannes
- Health Financing Department, Clinton Health Access Initiative, Addis Ababa, Ethiopia
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Mulongo SM, Kaura D, Mash B. Self-reported continuity and coordination of antenatal care and its association with obstetric near miss in Uasin Gishu county, Kenya. Afr J Prim Health Care Fam Med 2023; 15:e1-e8. [PMID: 36744454 PMCID: PMC9900303 DOI: 10.4102/phcfm.v15i1.3452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/23/2022] [Accepted: 06/22/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Continuity and coordination of care are core principles of high-quality primary health care. Optimising continuity and coordination improves maternal satisfaction. However, their association with morbidity and mortality outcomes is unclear. The obstetric near-miss approach can be used to investigate whether continuity and coordination influences the occurrence of a severe maternal outcome. AIM To compare self-reported continuity and coordination of care between obstetric near-miss survivors and those without near miss during pregnancy, delivery and postpartum. SETTING Uasin Gishu county, Rift Valley region, Kenya. METHODS A cross-sectional survey targeting 340 postnatal mothers. Continuity of care index (COCI) and modified continuity of care index (MCCI) were used to estimate longitudinal continuity. The Likert scale was administered to measure perceived continuity and coordination of care. Mann-Whitney U test and binomial logistic regression were used for hypothesis testing. RESULTS COCI and MCCI were lower among near-miss survivors (COCI = 0.80, p = 0.0026), (MCCI = 0.62, p = 0.034). Near-miss survivors scored lower on items assessing coordination between a higher-level provider and usual antenatal clinic (mean = 3.6, p = 0.006) and general coordination of care during pregnancy (mean = 3.9, p = 0.019). Presence of a non-life-threatening morbidity in pregnancy was associated with occurrence of near miss (aOR = 4.34, p = 0.001). CONCLUSION Near-miss survivors scored lower on longitudinal continuity and coordination of care across levels. Further research should focus on strengthening coordination, determining the optimal level of longitudinal continuity and improving systems for early identification and management of morbidities in pregnancy.Contribution: The results of this study show that while longitudinal and relational COC is important during the antenatal period, the presence of a non-life-threatening condition in pregnancy remains the most important predictor of the occurrence of a near miss.
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Affiliation(s)
- Samuel M. Mulongo
- Department of Nursing, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Doreen Kaura
- Department of Nursing, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Bob Mash
- Department of Family and Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Wilson S, Bah MM, George P, Caulker A, Holmer H, Leather AJ, Kamara TB. Challenges and solutions to providing surgery in Sierra Leone hospitals: a qualitative analysis of surgical provider perspectives. BMJ Open 2022; 12:e052972. [PMID: 35105579 PMCID: PMC8808401 DOI: 10.1136/bmjopen-2021-052972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This study aimed to use qualitative interviews with surgical providers to explore challenges and solutions to providing surgical and anaesthesia care in Sierra Leone's hospitals. DESIGN Data were collected through anonymous, semistructured interviews. We used a qualitative framework approach to analyse interview data and determine themes relating to challenges that were reported. SETTING A purposive sample of 12 hospitals was selected throughout Sierra Leone to include district and referral hospitals of varying ownership (private, non-governmental organisation and government). PARTICIPANTS The most senior surgical provider available during each hospital site visit participated in a semistructured interview. A total of 12 interviews were conducted. RESULTS Providers described both challenges and solutions relating to the following categories: equipment and supplies, access to services, human resources, infrastructure, management and patient factors. These challenges were found to affect surgical care in hospitals by delaying surgical care, decreasing operative capacity and decreasing quality of care. Providers identified not only the root causes of these challenges, but also the varied workarounds and solutions they employ to overcome them. CONCLUSION Surgical providers can offer important insights into challenges affecting surgical services in hospitals. Despite working in challenging environments with limited resources, providers have developed innovative solutions to improve surgical and anaesthesia care in hospitals in Sierra Leone. Qualitative research has an important role to play in improving understanding of the challenges facing surgeons in low-income countries.
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Affiliation(s)
- Spencer Wilson
- General Surgery, Boston Medical Center, Boston, Massachusetts, USA
| | - Mohamed M Bah
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Peter George
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Augustus Caulker
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Hampus Holmer
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Andrew Jm Leather
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
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Onchonga D, Alfatafta H, Ngetich E, Makunda W. Health-seeking behaviour among pregnant women during the COVID-19 pandemic: A qualitative study. Heliyon 2021; 7:e07972. [PMID: 34541362 PMCID: PMC8432977 DOI: 10.1016/j.heliyon.2021.e07972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 08/12/2021] [Accepted: 09/08/2021] [Indexed: 12/23/2022] Open
Abstract
Background The novel coronavirus pandemic has killed millions of people globally while significantly destroying the social, economic, and political wellbeing of people. The global pandemic has negatively impacted pregnant women's access to prenatal care. The current study sought to understand the health-seeking behaviour of women who were pregnant during the onset of the COVID-19 pandemic in Kenya. Methods The “Three Delay” model theoretical framework was applied to piece together the pregnant women's health-seeking behaviour during the early stages of the pandemic through focus group discussions. The collected qualitative data was analysed using thematic analysis. Results The delays in deciding to seek care, delays in reaching healthcare facilities and delays in receiving quality healthcare services at the healthcare facility were a result of the fear of contracting the virus. These delays were occasioned by participants’ personal experiences and uncertainties about COVID-19 pandemic, compulsory quarantines, national cessation of movements, compulsory lockdowns, loss of income to many households and the influence of traditional birth attendants (TBAs). Conclusion The current study found that fear of COVID-19 was a major factor that hindered access to maternal healthcare services. In this regard, there is a need to upscale awareness creation on the significance of seeking maternal health services during the pandemic to reduce the possibility of obliterating the gains made in reducing poor health-seeking behaviours among pregnant women.
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Affiliation(s)
- David Onchonga
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Hungary
| | - Huda Alfatafta
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Hungary
| | - Enoch Ngetich
- School of Public Health, Mount Kenya University-Nairobi, Kenya
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Shiferaw MA, Bekele D, Surur F, Dereje B, Tolu LB. Maternal Death Review at a Tertiary Hospital in Ethiopia. Ethiop J Health Sci 2021; 31:35-42. [PMID: 34158750 PMCID: PMC8188111 DOI: 10.4314/ejhs.v31i1.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background There is conflicting data on the rate and trends of maternal mortality in Ethiopia. There is no previous study done on the magnitude and trends of maternal death at Saint Paul's Hospital, an institution providing the largest labor and delivery services in Ethiopia. The objective of this study is to determine the magnitude, causes and contributing factors for maternal deaths in the institution. Methods We conducted a retrospective review of maternal deaths from January 2016 to December 2017. Data were analyzed using SPSS version 20. Results The maternal mortality ratio of the institution was 228.3 per 100,000 live births. Direct maternal death accounted for 90% (n=36) of the deceased. The leading causes of the direct maternal deaths were hypertensive disorders of pregnancy (n=13, 32.5%), postpartum hemorrhage (n=10, 25%), sepsis (n=4, 10%), pulmonary thromboembolism (n=3, 7.5%) and amniotic fluid embolism (n=3, 7.5%). Conclusion The maternal mortality ratio was lower than the ratios reported from other institutions in Ethiopia. Hypertensive disorders of pregnancy and malaria were the leading cause of direct and indirect causes of maternal deaths respectively. Embolism has become one of the top causes of maternal death in a rate like the developed nations. This might show the double burden of embolism and other causes of maternal mortality that developing countries might be facing.
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Affiliation(s)
- Matiyas Asrat Shiferaw
- Department of obstetrics and gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Delayehu Bekele
- Department of obstetrics and gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Feiruz Surur
- Department of obstetrics and gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Bethel Dereje
- Department of obstetrics and gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Lemi Belay Tolu
- Department of obstetrics and gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Agasaro O, Munezero G, Wong R, Hirwa A, Bekele A. Assessment of Delays in Emergency Surgical Care and Patient Postoperative Outcomes at a Referral Hospital in Northern Rwanda. World J Surg 2021; 45:1678-1685. [PMID: 33635340 DOI: 10.1007/s00268-021-06013-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical interventions are cost-effective methods to save lives and prevent disabilities. Surgical delays and access to three Bellwether procedures are key monitoring indicators for universal access to safe and affordable surgical and anesthesia care and health system performance. This study assessed the delays in receiving surgical and anesthesia care for emergency surgical patients at a district hospital in Northern Rwanda. METHODS A questionnaire was used to survey all emergency surgical patients who presented at the hospital between May and July 2020, to assess the delays in seeking (first) and reaching (second) care. In-hospital (third) delay and patient outcomes within the first 7 days postsurgery were collected by patient file auditing. Factors associated with third delay were identified through healthcare provider in-depth interviews. RESULTS A total of 106 patients were surveyed, and nine healthcare providers were interviewed. The median was less than a day for first delay, 1 day for second delay, and 16.5 h for third delay for all emergency procedures. 20% of the Bellwether procedures were performed within two hours after arriving at the hospital. Factors affecting the delays included visiting a traditional healer, district of residence, referral system, income status, as well as shortage of surgeons and specialists, surgical supplies, and operating theaters. CONCLUSION Further research to study the cause of delays within the referral system is needed. Surgical outreach, equipment, and infrastructure would help to shorten in-hospital delays. Longer-term follow-up studies on patient complications and outcomes due to delay in surgical care are needed.
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Affiliation(s)
- Orietta Agasaro
- University of Global Health Equity, Kigali, PO Box 6955, Kigali, Rwanda.
| | | | - Rex Wong
- University of Global Health Equity, Kigali, PO Box 6955, Kigali, Rwanda.,School of Public Health, Yale University, 60 College St, New Haven, CT, 06510, USA
| | | | - Abebe Bekele
- University of Global Health Equity, Kigali, PO Box 6955, Kigali, Rwanda
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Owolabi O, Riley T, Juma K, Mutua M, Pleasure ZH, Amo-Adjei J, Bangha M. Incidence of maternal near-miss in Kenya in 2018: findings from a nationally representative cross-sectional study in 54 referral hospitals. Sci Rep 2020; 10:15181. [PMID: 32939022 PMCID: PMC7495416 DOI: 10.1038/s41598-020-72144-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 08/26/2020] [Indexed: 02/08/2023] Open
Abstract
Although the Kenyan government has made efforts to invest in maternal health over the past 15 years, there is no evidence of decline in maternal mortality. To provide necessary evidence to inform maternal health care provision, we conducted a nationally representative study to describe the incidence and causes of maternal near-miss (MNM), and the quality of obstetric care in referral hospitals in Kenya. We collected data from 54 referral hospitals in 27 counties. Individuals admitted with potentially life-threatening conditions (using World Health Organization criteria) in pregnancy, childbirth or puerperium over a three month study period were eligible for inclusion in our study. All cases of severe maternal outcome (SMO, MNM cases and deaths) were prospectively identified, and after consent, included in the study. The national annual incidence of MNM was 7.2 per 1,000 live births and the intra-hospital maternal mortality ratio was 36.2 per 100,000 live births. The major causes of SMOs were postpartum haemorrhage and severe pre-eclampsia/eclampsia. However, only 77% of women with severe preeclampsia/eclampsia received magnesium sulphate and 67% with antepartum haemorrhage who needed blood received it. To reduce the burden of SMOs in Kenya, there is need for timely management of complications and improved access to essential emergency obstetric care interventions.
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Affiliation(s)
- Onikepe Owolabi
- Research Division, Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY, 10038, USA.
| | - Taylor Riley
- Research Division, Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY, 10038, USA
| | - Kenneth Juma
- Population Dynamics, Sexual and Reproductive Health Unit, African Population Health and Research Center, Manga Close, Nairobi, Kenya
| | - Michael Mutua
- Population Dynamics, Sexual and Reproductive Health Unit, African Population Health and Research Center, Manga Close, Nairobi, Kenya
| | - Zoe H Pleasure
- Research Division, Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY, 10038, USA
| | | | - Martin Bangha
- Population Dynamics, Sexual and Reproductive Health Unit, African Population Health and Research Center, Manga Close, Nairobi, Kenya
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Experiences of using the toll-free telephone line to access maternal and newborn health services in central Uganda: a qualitative study. Public Health 2019; 179:1-8. [PMID: 31698207 DOI: 10.1016/j.puhe.2019.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 09/14/2019] [Accepted: 09/20/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Save the Mothers (STM) operates the toll-free telephone line (TFL) service in nine health facilities in Uganda. The TFL is influential in addressing the first and second delays in seeking care as it connects vulnerable mothers to health facilities at no cost. This study aimed at exploring the experiences of health workers and community members in using the TFL to access maternal and newborn health services in four health facilities in central Uganda. STUDY DESIGN This phenomenological/qualitative study used focus group discussions (FGDs) to collect data in four health facilities. METHODS A total of 10 FGDs were conducted; two with health workers, four with women, and another four with both men and women. Each session lasted 45-60 min and had a moderator, observer, and note taker. All discussions were audio-recorded after obtaining consent from the participants. Interviews were transcribed verbatim and translated to English from audio recordings. Data analysis was performed using the thematic analysis using QDA DATA Miner software. RESULTS The TFL service was pivotal in improving health worker and community relations, relaying timely health advice, ensuring prompt response to obstetric emergencies and facilitated timely referrals. However, the service faced several obstacles: unanswered calls, language differences, poor connectivity/network, and misuse/abuse. CONCLUSION This study demonstrates the potential of the TFL service in addressing the first and second delay as it allows for timely linkage of vulnerable mothers to health facilities. The TFL enhanced health worker and community relations and facilitated timely referrals and relaying of health advice. Addressing maternal mortality in low-income settings necessitates increased investment and scale up of such high-impact mHealth interventions.
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Alemu FM, Fuchs MC, Martin Vitale T, Abdalla Mohamed Salih M. Severe maternal morbidity (near-miss) and its correlates in the world's newest nation: South Sudan. Int J Womens Health 2019; 11:177-190. [PMID: 30936753 PMCID: PMC6429996 DOI: 10.2147/ijwh.s160022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This study investigates the frequency of near-miss events and compares correlates in the world's newest nation. Methods A cross-sectional study was carried out to audit near-miss events and their causes. A total of 1,041 mothers were sampled. Data were gathered using World Health Organization near-miss evaluation tools according to morbidity and organ failure-based criteria. Intensive care unit admission criteria were not used (as there is no functional intensive care unit in Juba Teaching Hospital). Descriptive statistics and bivariate and multivariable logistic regression were used to analyze the data. The study adhered to the Declaration of Helsinki. Results Nearly half (49.7%) of the clients were young pregnant women (aged 15-24 years), with a mean age of 25.07±5.65 years. During the study period, there were 994 deliveries, 94 near-misses, and 10 maternal deaths. This resulted in maternal near-miss and mortality rates of 94.1 per 1,000 and 1,007 per 100,000 live births, respectively. Severe maternal outcome and maternal near-miss rates were 10.47 per 1,000 (morbidity-based criteria) and 41.3 per 1,000 (organ failure-based criteria), respectively. The likelihood of mortality was 25% (95% CI 10%-51%) for a ruptured uterus, 9% (95% CI 4%-17%) for severe postpartum hemorrhage, and 11% (95% CI 3%-30%) for eclampsia. Anemia, hemorrhage, and dystocia were the highest contributory factors in the occurrence of maternal near-misses. Conclusion The near-miss rate was high. Contributing factors were lack of resources, low quality of primary health care, and delays in care. All near-misses should be regarded as opportunities to improve the quality of maternity care. Health institutes should address delays in conducting interventions, referral barriers, and personnel gaps. Fully functional intensive-care units must be created in all facilities, including Juba Teaching Hospital and other hospitals. Notification policies for all near-miss cases should be in place in all health care units, with a "no shame, no blame" approach.
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Geleto A, Chojenta C, Musa A, Loxton D. Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa: a systematic review of literature. Syst Rev 2018; 7:183. [PMID: 30424808 PMCID: PMC6234634 DOI: 10.1186/s13643-018-0842-2] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women's access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa. METHODS Articles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings. RESULT The search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff. CONCLUSIONS A number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017074102.
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Affiliation(s)
- Ayele Geleto
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia. .,Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia.
| | - Catherine Chojenta
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia
| | - Abdulbasit Musa
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia.,School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Deborah Loxton
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia
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Saleh Gargari S, Essén B, Fallahian M, Mulic-Lutvica A, Mohammadi S. Auditing the appropriateness of cesarean delivery using the Robson classification among women experiencing a maternal near miss. Int J Gynaecol Obstet 2018; 144:49-55. [PMID: 30353540 DOI: 10.1002/ijgo.12698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 08/08/2018] [Accepted: 10/22/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate appropriateness of cesarean delivery and cesarean delivery-related morbidity among maternal near misses (MNMs) using the Robson ten-group classification system. METHODS In the present audit study, medical records were assessed for women who experienced MNM and underwent cesarean delivery at three university hospitals in Tehran, Iran, between March 1, 2012, and May 1, 2014. Local auditors assessed cesarean delivery indications and morbidity experienced. All records were re-assessed using Swedish obstetric guidelines. Findings were reported using the Robson ten-group classification system. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS Of the 61 women included, cesarean deliveries were more likely to be considered appropriate by local auditors compared with Swedish ones (OR 2.7, 95% CI 1.3-5.7). Cesarean delivery-related morbidity was attributed to near-miss events for 10 (16%) MNMs and was found to have aggravated 25 (41%). Of 16 women classified as Robson group 1-4, cesarean delivery-related MNM was identified in 15 (94%), compared with 13 (43%) of 30 women in group 10. Cesarean delivery with appropriate indication was associated with very low likelihood of cesarean delivery-related MNM (OR 0.2, 95% CI 0.1-0.6). CONCLUSION Cesarean delivery in the absence of appropriate indication could be an unsafe delivery choice. Audits using the Robson classification system facilitate understanding inappropriate cesarean delivery and its impact on maternal health.
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Affiliation(s)
- Soraya Saleh Gargari
- Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Birgitta Essén
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Masoumeh Fallahian
- Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ajlana Mulic-Lutvica
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Soheila Mohammadi
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
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Hutchinson K, Bryant M, Bachman DeSilva M, Price D, Sabin L, Bryson L, Jean Charles R, Declercq E. Delayed access to emergency obstetrical care among preeclamptic and non-preeclamptic women in Port-Au-Prince, Haiti. BMC Pregnancy Childbirth 2018; 18:337. [PMID: 30126377 PMCID: PMC6102923 DOI: 10.1186/s12884-018-1961-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 08/02/2018] [Indexed: 11/10/2022] Open
Abstract
Background The primary objective of this comparative, cross-sectional study was to identify factors affecting delays in accessing emergency obstetric care and clinical consequences of delays among preeclamptic and non-preeclamptic women in Port-au-Prince, Haiti. Methods We administered 524 surveys to women admitted to the Médecins Sans Frontières Centre de Référence en Urgences Obstétricales (CRUO) obstetric emergency hospital. Survey questions addressed first (at home), second (transport) and third (health facility) delays; demographic, clinical, and behavioral risk factors for delay; and clinical outcomes for women and infants. Bivariate statistics assessed relationships between preeclampsia status and delay, and between risk factors and delay. Results We found longer delays to care for preeclamptic women (mean 14.6 h, SD 27.9 versus non-preeclamptic mean 6.8 h, SD 10.5, p < 0.01), primarily attributable to delays before leaving for hospital (mean 13.4 h, SD 30.0 versus non-preeclamptic mean 5.5 h, SD 10.5). Few demographic, clinical, or behavioral factors were associated with care access. Poor outcomes were more likely among preeclamptic women and infants, including intensive care unit admission (10.7%, vs. 0.5% among non-preeclamptic women, p < 0.01) and eclampsia (10.7% vs. no cases, p < 0.01) for women, and neonatal care unit admission (45.6% vs. 15.4%, p < 0.01) and stillbirth (9.9% vs. 0.5%, p < 0.01). Longer delays among both groups were not associated with poorer clinical outcomes. Conclusion Pregnant women with preeclampsia in Port-au-Prince reported significant delays in accessing emergency obstetric care. This study provides clear evidence that hospital proximity alone does not mitigate the long delays in accessing emergency obstetrical care for Haitian urban, poor women.
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Affiliation(s)
- Katharine Hutchinson
- Médecins Sans Frontières and Boston University School of Public Health, 715 Albany Street, Boston, 02118, USA.
| | | | | | - Deborah Price
- Médecins Sans Frontières, Amsterdam, the Netherlands
| | - Lora Sabin
- Boston University School of Public Health, Boston, USA
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Chavane LA, Bailey P, Loquiha O, Dgedge M, Aerts M, Temmerman M. Maternal death and delays in accessing emergency obstetric care in Mozambique. BMC Pregnancy Childbirth 2018; 18:71. [PMID: 29566655 PMCID: PMC5863898 DOI: 10.1186/s12884-018-1699-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 03/02/2018] [Indexed: 01/15/2023] Open
Abstract
Background Despite declining trends maternal mortality remains an important public health issue in Mozambique. The delays to reach an appropriate health facility and receive care faced by woman with pregnancy related complications play an important role in the occurrence of these deaths. This study aims to examine the contribution of the delays in relation to the causes of maternal death in facilities in Mozambique. Methods Secondary analysis was performed on data from a national assessment on maternal and neonatal health that included in-depth maternal death reviews, using patient files and facility records with the most comprehensive information available. Statistical models were used to assess the association between delay to reach the health facility that provides emergency obstetric care (delay type II) and delay in receiving appropriate care once reaching the health facility providing emergency obstetric care (delay type III) and the cause of maternal death within the health facility. Results Data were available for 712 of 2,198 maternal deaths. Delay type II was observed in 40.4% of maternal deaths and delay type III in 14.2%.and 13.9% had both delays. Women who died of a direct obstetric complication were more likely to have experienced a delay type III than women who died due to indirect causes. Women who experienced delay type II were less likely to have also delay type III and vice versa. Conclusions The delays in reaching and receiving appropriate facility-based care for women facing pregnancy related complications in Mozambique contribute significantly to maternal mortality. Securing referral linkages and health facility readiness for rapid and correct patient management are needed to reduce the impact of these delays within the health system.
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Affiliation(s)
| | - Patricia Bailey
- RMNCH Unit, Global Health Programs, FHI, Durham, NC, 360, USA
| | - Osvaldo Loquiha
- Department of Mathematics and Informatics, Eduardo Mondlane University, Maputo, Mozambique
| | - Martinho Dgedge
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Marc Aerts
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BioStat), Hasselt University, Hasselt, Belgium
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health- East Africa, Aga Khan University, Karachi, Pakistan.,Ghent University Belgium, Ghent, Belgium
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Mekango DE, Alemayehu M, Gebregergs GB, Medhanyie AA, Goba G. Determinants of maternal near miss among women in public hospital maternity wards in Northern Ethiopia: A facility based case-control study. PLoS One 2017; 12:e0183886. [PMID: 28886034 PMCID: PMC5590854 DOI: 10.1371/journal.pone.0183886] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 08/10/2017] [Indexed: 11/18/2022] Open
Abstract
Background In Ethiopia, 20,000 women die each year from complications related to pregnancy, childbirth and post-partum. For every woman that dies, 20 more experience injury, infection, disease, or disability. “Maternal near miss” (MNM), defined by the World Health Organization (WHO) as a woman who nearly dies, but survives a complication during pregnancy, childbirth or within 42 days of a termination, is a proxy indicator of maternal mortality and quality of obstetric care. In Ethiopia, few studies have examined MNM. This study aims to identify determinants of MNM among a small population of women in Tigray, Ethiopia. Methods Unmatched case-control study was conducted in hospitals in Tigray Region, Northern Ethiopia, from January 30-March 30, 2016. The sample included 103 cases and 205 controls recruited from among women seeking obstetric care at six (6) public hospitals. Clients with life-threatening obstetric complications, including hemorrhage, hypertensive diseases of pregnancy, dystocia, infection, and anemia or clinical signs of severe anemia (in women without hemorrhage) were taken as cases and those with normal obstetric outcomes were controls. Cases were selected based on proportion to size allocation while systematic sampling was employed for controls. Binary and multiple variable logistic regression (“odds ratio”) analyses were calculated at 95% CI. Results Roughly 90% of cases and controls were married and 25% experienced their first pregnancy before the age of 16 years. About two-thirds of controls and 45.6% of cases had gestational ages between 37–41 weeks. Among cases, severe obstetric hemorrhage (44.7%), hypertensive disorders (38.8%), dystocia (17.5%), sepsis (9.7%) and severe anemia (2.9%) were leading causes of MNM. Histories of chronic maternal medical problems like hypertension, diabetes were reported in 55.3% of cases and 33.2% of controls. Women with no formal education [AOR = 3.2;95%CI:1.24, 8.12], being less than 16 years of age at first pregnancy [AOR = 2.5;95%CI:1.12,5.63], induced labor[AOR = 3.0; 95%CI:1.44, 6.17], history of cesarean section[AOR = 4.6; 95% CI: 1.98, 7.61] or chronic medical disorder[AOR = 3.5;95%CI:1.78, 6.93], and women who traveled more than 60 minutes before reaching their final place of care[AOR = 2.8;95% CI: 1.19,6.35] had higher odds of experiencing MNM. Conclusions Macro-developments like increasing road and health facility access as well as expanding education will all help reduce MNM. Work should be continued to educate women and providers about common predictors of MNM like history of C-section and chronic illness as well as teenage pregnancy. These efforts should be carried out at the facility, community, and individual levels. Targeted follow-up with women with history of chronic disease and C-section could also help reduce MNM.
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Affiliation(s)
- Dejene Ermias Mekango
- Wachemo University, College of Medicine and Health Sciences, Department of Public Health, Hosanna, Ethiopia
- * E-mail:
| | - Mussie Alemayehu
- Mekelle University, College of Health Sciences, School of Public Health, Mekelle, Ethiopia
| | | | - Araya Abrha Medhanyie
- Mekelle University, College of Health Sciences, School of Public Health, Mekelle, Ethiopia
| | - Gelila Goba
- University of Illinois at Chicago, Department of Obstetrics and Gynecology, Chicago, Illinois
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Mgawadere F, Unkels R, Kazembe A, van den Broek N. Factors associated with maternal mortality in Malawi: application of the three delays model. BMC Pregnancy Childbirth 2017; 17:219. [PMID: 28697794 PMCID: PMC5506640 DOI: 10.1186/s12884-017-1406-5] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 07/03/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The three delays model proposes that maternal mortality is associated with delays in: 1) deciding to seek care; 2) reaching the healthcare facility; and 3) receiving care. Previously, the majority of women who died were reported to have experienced type 1 and 2 delays. With increased coverage of healthcare services, we sought to explore the relative contribution of each type of delay. METHOD 151 maternal deaths were identified during a 12-month reproductive age mortality survey (RAMOS) conducted in Malawi; verbal autopsy and facility-based medical record reviews were conducted to obtain details about the circumstances surrounding each death. Using the three delays framework, data were analysed for women who had; 1) died at a healthcare facility, 2) died at home but had previously accessed care and 3) died at home and had not accessed care. RESULTS 62.2% (94/151) of maternal deaths occurred in a healthcare facility and a further 21.2% (32/151) of mothers died at home after they had accessed care at a healthcare facility. More than half of all women who died at a healthcare facility (52.1%) had experienced more than one type of delay. Type 3 delays were the most significant delay for women who died at a healthcare facility or women who died at home after they had accessed care, and was identified in 96.8% of cases. Type 2 delays were experienced by 59.6% and type 1 delays by 39.7% of all women. Long waiting hours before receiving treatment at a healthcare facility, multiple delays at the time of admission, shortage of drugs, non-availability and incompetence of skilled staff were some of the major causes of type 3 delays. Distance to a healthcare facility was the main problem resulting in type 2 delays. CONCLUSION The majority of women do try to reach health services when an emergency occurs, but type 3 delays present a major problem. Improving quality of care at healthcare facility level will help reduce maternal mortality.
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Affiliation(s)
- Florence Mgawadere
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Regine Unkels
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Abigail Kazembe
- Kamuzu College of Nursing, University of Malawi, Zomba, Malawi
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
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Mohammadi S, Carlbom A, Taheripanah R, Essén B. Experiences of inequitable care among Afghan mothers surviving near-miss morbidity in Tehran, Iran: a qualitative interview study. Int J Equity Health 2017; 16:121. [PMID: 28687082 PMCID: PMC5500928 DOI: 10.1186/s12939-017-0617-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 06/28/2017] [Indexed: 11/29/2022] Open
Abstract
Background Providing equitable maternal care to migrants is a seriously challenging task for hosting countries. Iran, the second-most accessed country for refugees from Afghanistan, has achieved maternal health improvement. However, Afghan women with near-miss morbidity faced pre-hospital delays and disparity in maternal care at hospitals. This study explores experiences of maternal care among Afghan women surviving near-miss morbidity to increase insight into healthcare improvements for migrants. Methods A qualitative study was conducted at university hospitals in Tehran, from April 2013 to May 2014. A total of 11 Afghan women and 4 husbands were interviewed when women recovered from near-miss morbidity that occurred around the childbirth period. Mothers were identified prospectively using the WHO maternal near-miss approach. Thematic analysis was used along with a data-driven approach to organize data guided by the ‘three delays model’ theoretical framework. Results Mistreatment in the form of discrimination and insufficient medical attention were key experiences. Participants commonly perceived poor women–professional communication and delays in recognizing obstetric complications despite repeated care-seeking. Financial constraints, costly care, lack of health insurance, and low literacy were experienced barriers to accessing care to a lesser extent. Non-somatic consequences of near-miss morbidity affected mothers and families for extended periods. Conclusions Near-miss survivors’ experiences provided remarkable insights into maternal care of Afghans in Iran. The challenge for the health system and professionals is to provide equitable care with dignity and improve communication skills with caring attitudes toward ethnic minorities. Antenatal visits provide the best and most appropriate opportunities to tackle health illiteracy in Afghan women.
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Affiliation(s)
- Soheila Mohammadi
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, SE-751 85, Uppsala, Sweden. .,Infertility and Reproductive Health Research Center (IRHRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Aje Carlbom
- Faculty of Health and Society, Malmö University, Malmö, Sweden
| | - Robabeh Taheripanah
- Infertility and Reproductive Health Research Center (IRHRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Birgitta Essén
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, SE-751 85, Uppsala, Sweden
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Towards an integrated primary and secondary HIV prevention continuum for the United States: a cyclical process model. J Int AIDS Soc 2016; 19:21263. [PMID: 27863535 PMCID: PMC5116064 DOI: 10.7448/ias.19.1.21263] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 10/03/2016] [Accepted: 10/24/2016] [Indexed: 01/30/2023] Open
Abstract
Introduction Every new HIV infection is preventable and every HIV-related death is avoidable. As many jurisdictions around the world endeavour to end HIV as an epidemic, missed HIV prevention and treatment opportunities must be regarded as public health emergencies, and efforts to quickly fill gaps in service provision for all people living with and vulnerable to HIV infection must be prioritized. Discussion We present a novel, comprehensive, primary and secondary HIV prevention continuum model for the United States as a conceptual framework to identify key steps in reducing HIV incidence and improving health outcomes among those vulnerable to, as well as those living with, HIV infection. We further discuss potential approaches to address gaps in data required for programme planning, implementation and evaluation across the elements of the HIV prevention continuum. Conclusions Our model conceptualizes opportunities to monitor and quantify primary HIV prevention efforts and, importantly, illustrates the interplay between an outcomes-oriented primary HIV prevention process and the HIV care continuum to move aggressively forward in reaching ambitious reductions in HIV incidence. To optimize the utility of this outcomes-oriented HIV prevention continuum, a key gap to be addressed includes the creation and increased coordination of data relevant to HIV prevention across sectors.
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Påfs J, Musafili A, Binder-Finnema P, Klingberg-Allvin M, Rulisa S, Essén B. Beyond the numbers of maternal near-miss in Rwanda - a qualitative study on women's perspectives on access and experiences of care in early and late stage of pregnancy. BMC Pregnancy Childbirth 2016; 16:257. [PMID: 27590589 PMCID: PMC5010768 DOI: 10.1186/s12884-016-1051-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 08/20/2016] [Indexed: 11/19/2022] Open
Abstract
Background Rwanda has made remarkable progress in decreasing the number of maternal deaths, yet women still face morbidities and mortalities during pregnancy. We explored care-seeking and experiences of maternity care among women who suffered a near-miss event during either the early or late stage of pregnancy, and identified potential health system limitations or barriers to maternal survival in this setting. Methods A framework of Naturalistic Inquiry guided the study design and analysis, and the ‘three delays’ model facilitated data sorting. Participants included 47 women, who were interviewed at three hospitals in Kigali, and 14 of these were revisited in their homes, from March 2013 to April 2014. Results The women confronted various care-seeking barriers depending on whether the pregnancy was wanted, the gestational age, insurance coverage, and marital status. Poor communication between the women and healthcare providers seemed to result in inadequate or inappropriate treatment, leading some to seek either traditional medicine or care repeatedly at biomedical facilities. Conclusion Improved service provision routines, information, and amendments to the insurance system are suggested to enhance prompt care-seeking. Additionally, we strongly recommend a health system that considers the needs of all pregnant women, especially those facing unintended pregnancies or complications in the early stages of pregnancy.
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Affiliation(s)
- Jessica Påfs
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska Sjukhuset, Uppsala University, SE-751 85, Uppsala, Sweden.
| | - Aimable Musafili
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska Sjukhuset, Uppsala University, SE-751 85, Uppsala, Sweden.,Department of Pediatrics and Child Health, College of Medicine and Health Sciences, School of Medicine, University of Rwanda, P.O. Box 217, Butare, Huye, Rwanda
| | - Pauline Binder-Finnema
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska Sjukhuset, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Marie Klingberg-Allvin
- School of Education, Health and Social Studies, Dalarna University, SE-791 88, Falun, Sweden
| | - Stephen Rulisa
- Department of Obstetrics & Gynecology, College of Medicine and Health Sciences, School of Medicine, University of Rwanda, P.O.Box 3286, Kigali, Rwanda.,Department of Clinical Research, University Teaching Hospital of Kigali, BP 655, Kigali, Rwanda
| | - Birgitta Essén
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska Sjukhuset, Uppsala University, SE-751 85, Uppsala, Sweden
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Barriers to essential surgical care experienced by women in the two northernmost regions of Ghana: a cross-sectional survey. BMC WOMENS HEALTH 2016; 16:27. [PMID: 27230890 PMCID: PMC4882854 DOI: 10.1186/s12905-016-0308-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 05/21/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND Women in developing countries might experience certain barriers to care more frequently than men. We aimed to describe barriers to essential surgical care that women face in five communities in Ghana. METHODS Questions regarding potential barriers were asked during surgical outreaches to five communities in the northernmost regions of Ghana. Responses were scored in three dimensions from 0 to 18 (i.e., 'acceptability,' 'affordability,' and 'accessibility'; 18 implied no barriers). A barrier to care index out of 10 was derived (10 implied no barriers). An open-ended question to elicit gender-specific barriers was also asked. RESULTS Of the 320 participants approached, 315 responded (response rate 98 %); 149 were women (47 %). Women had a slightly lower barriers to surgical care index (median index 7.4; IQR 3.9-9.1) than men (7.9; IQR 3.9-9.4; p = 0.002). Compared with men, women had lower accessibility and acceptability dimension scores (14.4/18 vs 14.4/18; p = 0.001 and 13.5/18 vs 14/18; p = 0.05, respectively), but similar affordability scores (13.5/18 vs 13.5/18; p = 0.13). Factors contributing to low dimension scores among women included fear of anesthesia, lack of social support, and difficulty navigating healthcare, as well as lack of hospital privacy and confidentiality. CONCLUSION Women had a slightly lower barriers to surgical care index than men, which may indicate greater barriers to surgical care. However, the actual significance of this difference is not yet known. Community-level education regarding the safety and benefits of essential surgical care is needed. Additionally, healthcare facilities must ensure a private and confidential care environment. These interventions might ameliorate some barriers to essential surgical care for women in Ghana, as well as other LMICs more broadly.
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Oladapo OT, Adetoro OO, Ekele BA, Chama C, Etuk SJ, Aboyeji AP, Onah HE, Abasiattai AM, Adamu AN, Adegbola O, Adeniran AS, Aimakhu CO, Akinsanya O, Aliyu LD, Ande AB, Ashimi A, Bwala M, Fabamwo A, Geidam AD, Ikechebelu JI, Imaralu JO, Kuti O, Nwachukwu D, Omo‐Aghoja L, Tunau K, Tukur J, Umeora OUJ, Umezulike AC, Dada OA, Tunçalp Ӧ, Vogel JP, Gülmezoglu AM. When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country. BJOG 2016; 123:928-38. [PMID: 25974281 PMCID: PMC5016783 DOI: 10.1111/1471-0528.13450] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals. DESIGN Nationwide cross-sectional study. SETTING Forty-two tertiary hospitals. POPULATION Women admitted for pregnancy, childbirth and puerperal complications. METHODS All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period. MAIN OUTCOME MEASURES Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO). RESULTS Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care. CONCLUSIONS Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care. TWEETABLE ABSTRACT Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.
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Affiliation(s)
- OT Oladapo
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of ResearchDevelopment and Research Training in Human Reproduction (HRP)World Health OrganizationGenevaSwitzerland
| | - OO Adetoro
- Department of Obstetrics and GynaecologyOlabisi Onabanjo University Teaching HospitalSagamuNigeria
| | - BA Ekele
- Department of Obstetrics and GynaecologyUniversity of Abuja Teaching HospitalGwagwaladaNigeria
| | - C Chama
- Department of Obstetrics and GynaecologyUniversity of Maiduguri Teaching HospitalMaiduguriNigeria
| | - SJ Etuk
- Department of Obstetrics and GynaecologyUniversity of Calabar Teaching HospitalCalabarNigeria
| | - AP Aboyeji
- Department of Obstetrics and GynaecologyUniversity of Ilorin Teaching HospitalIlorinNigeria
| | - HE Onah
- Department of Obstetrics and GynaecologyUniversity of Nigeria Teaching HospitalEnuguNigeria
| | - AM Abasiattai
- Department of Obstetrics and GynaecologyUniversity of Uyo Teaching HospitalUyoNigeria
| | - AN Adamu
- Department of Obstetrics and GynaecologyFederal Medical CentreBirnin‐KebbiNigeria
| | - O Adegbola
- Department of Obstetrics and GynaecologyLagos University Teaching HospitalIdi‐ArabaNigeria
| | - AS Adeniran
- Department of Obstetrics and GynaecologyUniversity of Ilorin Teaching HospitalIlorinNigeria
| | - CO Aimakhu
- Department of Obstetrics and GynaecologyUniversity College HospitalIbadanNigeria
| | - O Akinsanya
- Department of Obstetrics and GynaecologyFederal Medical CentreOwoNigeria
| | - LD Aliyu
- Department of Obstetrics and GynaecologyAbubakar Tafawa Balewa University Teaching HospitalBauchiNigeria
| | - AB Ande
- Department of Obstetrics and GynaecologyUniversity of Benin Teaching HospitalBenin‐CityNigeria
| | - A Ashimi
- Department of Obstetrics and GynaecologyFederal Medical CentreBirnin‐KuduNigeria
| | - M Bwala
- Department of Obstetrics and GynaecologyFederal Medical CentreNguruNigeria
| | - A Fabamwo
- Department of Obstetrics and GynaecologyLagos State University Teaching HospitalIkejaNigeria
| | - AD Geidam
- Department of Obstetrics and GynaecologyUniversity of Maiduguri Teaching HospitalMaiduguriNigeria
| | - JI Ikechebelu
- Department of Obstetrics and GynaecologyNnamdi Azikwe University Teaching HospitalNnewiNigeria
| | - JO Imaralu
- Department of Obstetrics and GynaecologyObafemi Awolowo University Teaching Hospital ComplexIle‐IfeNigeria
| | - O Kuti
- Department of Obstetrics and GynaecologyObafemi Awolowo University Teaching Hospital ComplexIle‐IfeNigeria
| | - D Nwachukwu
- Department of Obstetrics and GynaecologyFederal Medical CentreBidaNigeria
| | - L Omo‐Aghoja
- Department of Obstetrics and GynaecologyDelta State University Teaching HospitalAbrakaNigeria
| | - K Tunau
- Department of Obstetrics and GynaecologyUsmanu DanFodiyo University Teaching HospitalSokotoNigeria
| | - J Tukur
- Department of Obstetrics and GynaecologyAminu Kano University Teaching HospitalKanoNigeria
| | - OUJ Umeora
- Department of Obstetrics and GynaecologyFederal University Teaching HospitalAbakalikiNigeria
| | - AC Umezulike
- Department of Obstetrics and GynaecologyNational HospitalAbujaNigeria
| | - OA Dada
- Centre for Research in Reproductive HealthSagamuNigeria
| | - Ӧ Tunçalp
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of ResearchDevelopment and Research Training in Human Reproduction (HRP)World Health OrganizationGenevaSwitzerland
| | - JP Vogel
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of ResearchDevelopment and Research Training in Human Reproduction (HRP)World Health OrganizationGenevaSwitzerland
| | - AM Gülmezoglu
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of ResearchDevelopment and Research Training in Human Reproduction (HRP)World Health OrganizationGenevaSwitzerland
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Ronsmans C, Cresswell JA, Goufodji S, Agbla S, Ganaba R, Assarag B, Tonouhéoua O, Diallo C, Meski FZ, Filippi V. Characteristics of neonatal near miss in hospitals in Benin, Burkina Faso and Morocco in 2012-2013. Trop Med Int Health 2016; 21:535-45. [PMID: 26892469 DOI: 10.1111/tmi.12682] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this study is to explore the usefulness of neonatal near miss in low- and middle-income countries by examining the incidence of neonatal near miss and pre-discharge neonatal deaths across various obstetric risk categories in 17 hospitals in Benin, Burkina Faso and Morocco. METHODS Data were collected on all maternal deaths, maternal near miss, neonatal near miss (based on organ-dysfunction markers), Caesarean sections, stillbirths, neonatal deaths before discharge and non-cephalic presentations, and on a sample of births not falling in any of the above categories. RESULTS The burden of stillbirth, pre-discharge neonatal death or neonatal near miss ranged from 23 to 129 per 1000 births in Moroccan and Beninese hospitals, respectively. Perinatal deaths (range 17-89 per 1000 births) were more common than neonatal near miss (range 6-43 per 1000 live births), and between a fifth and a third of women who had suffered a maternal near miss lost their baby. Pre-discharge neonatal deaths and neonatal near miss had a similar distribution of markers of organ dysfunction, but unlike pre-discharge neonatal deaths most neonatal near miss (63%, 81% and 71% in Benin, Burkina Faso and Morocco, respectively) occurred among babies who were not considered premature, low birthweight or with a low 5-min Apgar score as defined by WHO's pragmatic markers of severe neonatal morbidity. CONCLUSION Whether the measurement of neonatal near miss adds useful insights into the quality of perinatal or newborn care in settings where facility-based intrapartum and early newborn mortality is very high is uncertain. Perhaps the greatest advantage of adding near miss is the shift in focus from failure to success so that lessons can be learned on how to save lives even when clinical conditions are life-threatening.
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Assarag B, Dujardin B, Delamou A, Meski FZ, De Brouwere V. Determinants of maternal near-miss in Morocco: too late, too far, too sloppy? PLoS One 2015; 10:e0116675. [PMID: 25612095 PMCID: PMC4303272 DOI: 10.1371/journal.pone.0116675] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 11/16/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In Morocco, there is little information on the circumstances surrounding maternal near misses. This study aimed to determine the incidence, characteristics, and determinants of maternal near misses in Morocco. METHOD A prospective case-control study was conducted at 3 referral maternity hospitals in the Marrakech region of Morocco between February and July 2012. Near-miss cases included severe hemorrhage, hypertensive disorders, and prolonged obstructed labor. Three unmatched controls were selected for each near-miss case. Three categories of risk factors (sociodemographics, reproductive history, and delays), as well as perinatal outcomes, were assessed, and bivariate and multivariate analyses of the determinants were performed. A sample of 30 near misses and 30 non-near misses was interviewed. RESULTS The incidence of near misses was 12‰ of births. Hypertensive disorders during pregnancy (45%) and severe hemorrhage (39%) were the most frequent direct causes of near miss. The main risk factors were illiteracy [OR = 2.35; 95% CI: (1.07-5.15)], lack of antenatal care [OR = 3.97; 95% CI: (1.42-11.09)], complications during pregnancy [OR = 2.81; 95% CI:(1.26-6.29)], and having experienced a first phase delay [OR = 8.71; 95% CI: (3.97-19.12)] and a first phase of third delay [OR = 4.03; 95% CI: (1.75-9.25)]. The main reasons for the first delay were lack of a family authority figure who could make a decision, lack of sufficient financial resources, lack of a vehicle, and fear of health facilities. The majority of near misses demonstrated a third delay with many referrals. The women's perceptions of the quality of their care highlighted the importance of information, good communication, and attitude. CONCLUSION Women and newborns with serious obstetric complications have a greater chance of successful outcomes if they are immediately directed to a functioning referral hospital and if the providers are responsive.
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Affiliation(s)
- Bouchra Assarag
- National School of Public Health, Rabat, Morocco
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Bruno Dujardin
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Delamou
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
- National Centre for Research and Training in Rural Health, Maferinyah, Guinea
| | | | - Vincent De Brouwere
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Bhattacharyya S, Srivastava A, Knight M. Developing a framework to review near-miss maternal morbidity in India: a structured review and key stakeholder analysis. BMC Health Serv Res 2014; 14:553. [PMID: 25391999 PMCID: PMC4232644 DOI: 10.1186/s12913-014-0553-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 10/24/2014] [Indexed: 11/10/2022] Open
Abstract
Background In India there is a thrust towards promoting institutional delivery, resulting in problems of overcrowding and compromise to quality of care. Review of near-miss obstetric events has been suggested to be useful to investigate health system functioning, complementing maternal death reviews. The aim of this project was to identify the key elements required for a near-miss review programme for India. Methods A structured review was conducted to identify methods used in assessing near-miss cases. The findings of the structured review were used to develop a suggested framework for conducting near-miss reviews in India. A pool of experts in near-miss review methods in low and middle income countries (LMICs) was identified for vetting the framework developed. Opinions were sought about the feasibility of implementing near-miss reviews in India, the processes to be followed, factors that made implementation successful and the associated challenges. A draft of the framework was revised based on the experts’ opinions. Results Five broad methods of near-miss case review/audit were identified: Facility-based near-miss case review, confidential enquiries, criterion-based clinical audit, structured case review (South African Model) and home-based interviews. The opinion of the 11 stakeholders highlighted that the methods that a facility adopts should depend on the type and number of cases the facility handles, availability and maintenance of a good documentation system, and local leadership and commitment of staff. A proposed framework for conducting near-miss reviews was developed that included a combination of criterion-based clinical audit and near-miss review methods. Conclusion The approach allowed for development of a framework for researchers and planners seeking to improve quality of maternal care not only at the facility level but also beyond, encompassing community health workers and referral. Further work is needed to evaluate the implementation of this framework to determine its efficacy in improving the quality of care and hence maternal and perinatal morbidity and mortality.
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Pacagnella RC, Cecatti JG, Parpinelli MA, Sousa MH, Haddad SM, Costa ML, Souza JP, Pattinson RC. Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. BMC Pregnancy Childbirth 2014; 14:159. [PMID: 24886330 PMCID: PMC4016777 DOI: 10.1186/1471-2393-14-159] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 04/29/2014] [Indexed: 11/23/2022] Open
Abstract
Background The vast majority of maternal deaths in low-and middle-income countries are preventable. Delay in obtaining access to appropriate health care is a fairly common problem which can be improved. The objective of this study was to explore the association between delay in providing obstetric health care and severe maternal morbidity/death. Methods This was a multicentre cross-sectional study, involving 27 referral obstetric facilities in all Brazilian regions between 2009 and 2010. All women admitted to the hospital with a pregnancy-related cause were screened, searching for potentially life-threatening conditions (PLTC), maternal death (MD) and maternal near-miss (MNM) cases, according to the WHO criteria. Data on delays were collected by medical chart review and interview with the medical staff. The prevalence of the three different types of delays was estimated according to the level of care and outcome of the complication. For factors associated with any delay, the PR and 95%CI controlled for cluster design were estimated. Results A total of 82,144 live births were screened, with 9,555 PLTC, MNM or MD cases prospectively identified. Overall, any type of delay was observed in 53.8% of cases; delay related to user factors was observed in 10.2%, 34.6% of delays were related to health service accessibility and 25.7% were related to quality of medical care. The occurrence of any delay was associated with increasing severity of maternal outcome: 52% in PLTC, 68.4% in MNM and 84.1% in MD. Conclusions Although this was not a population-based study and the results could not be generalized, there was a very clear and significant association between frequency of delay and severity of outcome, suggesting that timely and proper management are related to survival.
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Affiliation(s)
| | - José G Cecatti
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.
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Hofman JJ, Mohammed H. Experiences with facility-based maternal death reviews in northern Nigeria. Int J Gynaecol Obstet 2014; 126:111-4. [PMID: 24834852 DOI: 10.1016/j.ijgo.2014.02.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 01/30/2014] [Accepted: 04/05/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of the maternal death review (MDR) system and process in improving quality of maternal and newborn health care in northern Nigeria. METHODS A combination of quantitative and qualitative methods was used, including review of MDR forms and of health management information system data on maternal deaths (MDs), as well as semi-structured interviews with members of 11 MDR committees. RESULTS Facility-based MDRs were initiated in 75 emergency obstetric and newborn care facilities in northern Nigeria and were initially conducted in the 33 hospitals; however, the process stopped after some time and had to be revitalized. Main reasons were transfer of key members of MDR committees, lack of supportive supervision, and shortage of staff. Ninety-three (12.1%) of 768 identified MDs were recorded on MDR forms and 52 (6.7%) had been reviewed. MDRs resulted in improved quality of care, including mobilization of additional resources. Challenges were fear of blame, shortage of staff, transfer of MDR team members, inadequate supportive supervision, and poor record keeping. CONCLUSION MDR requires teamwork, commitment, and champions at health facility level to spearhead the process. MDR needs to be institutionalized in the Ministry of Health, which provides oversight, policy guidance, and support, including supportive supervision.
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Affiliation(s)
| | - Hauwa Mohammed
- Department of Obstetrics and Gynaecology, Federal Medical Centre, Nguru, Nigeria
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Krain LJ, Atwell JE, Nelson KE, Labrique AB. Fetal and neonatal health consequences of vertically transmitted hepatitis E virus infection. Am J Trop Med Hyg 2014; 90:365-70. [PMID: 24420778 DOI: 10.4269/ajtmh.13-0265] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hepatitis E virus (HEV) infections lead to tens of thousands of deaths annually, mostly in developing countries. Hepatitis E poses a significant threat to the health of expectant mothers, a well-noted epidemiologic feature of the disease, but the contribution of vertically transmitted HEV infection to fetal and neonatal morbidity and mortality has received limited attention. Evidence assembled to date suggests that mother-to-child HEV transmission may be frequent and deleterious to the fetus and newborn in pregnancies affected by hepatitis E. Additional work is required to resolve key questions. (1) What risks do subclinical maternal HEV infections and infections early in pregnancy pose to fetal health and development? (2) Does vertical transmission occur during labor and/or breastfeeding and contribute appreciably to neonatal morbidity and mortality? (3) How do treatment decisions for severely ill mothers affect fetal and neonatal outcomes? (4) Can maternal vaccination effectively prevent vertical transmission of HEV?
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Affiliation(s)
- Lisa J Krain
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Emergency care capacity in Africa: a clinical and educational initiative in Tanzania. J Public Health Policy 2013; 33 Suppl 1:S126-37. [PMID: 23254838 PMCID: PMC3530028 DOI: 10.1057/jphp.2012.41] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Even though sub-Saharan Africa faces a disproportionate burden of acute injury and illness, few clinical facilities are configured to take an integrated approach to resuscitation and stabilization. Emergency care is a high-impact and cost-effective form of secondary prevention; disease surveillance at facilities delivering acute and emergency care is essential to guide primary prevention. Barriers to emergency care implementation in the region include limited documentation of the acute disease burden, a lack of consensus on regionally appropriate metrics to facilitate impact evaluation, and the lack of coordinated advocacy for acute disease prevention and emergency care. Despite these challenges, interest in creating dedicated acute care facilities and emergency training programs is rapidly expanding in Africa. We describe one such initiative at Muhimbili National Hospital in Dar es Salaam, with a focus on the development of the emergency medicine residency program.
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Lobato G, Nakamura-Pereira M, Mendes-Silva W, Dias MA, Reichenheim ME. Comparing different diagnostic approaches to severe maternal morbidity and near-miss: a pilot study in a Brazilian tertiary hospital. Eur J Obstet Gynecol Reprod Biol 2013. [DOI: 10.1016/j.ejogrb.2012.10.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pacagnella RC, Cecatti JG, Osis MJ, Souza JP. The role of delays in severe maternal morbidity and mortality: expanding the conceptual framework. REPRODUCTIVE HEALTH MATTERS 2012; 20:155-63. [PMID: 22789093 DOI: 10.1016/s0968-8080(12)39601-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Maternal mortality has gained importance in research and policy since the mid-1980s. Thaddeus and Maine recognized early on that timely and adequate treatment for obstetric complications were a major factor in reducing maternal deaths. Their work offered a new approach to examining maternal mortality, using a three-phase framework to understand the gaps in access to adequate management of obstetric emergencies: phase I--delay in deciding to seek care by the woman and/or her family; phase II--delay in reaching an adequate health care facility; and phase III--delay in receiving adequate care at that facility. Recently, efforts have been made to strengthen health systems' ability to identify complications that lead to maternal deaths more rapidly. This article shows that the combination of the "three delays" framework with the maternal "near-miss" approach, and using a range of information-gathering methods, may offer an additional means of recognizing a critical event around childbirth. This approach can be a powerful tool for policymakers and health managers to guarantee the principles of human rights within the context of maternal health care, by highlighting the weaknesses of systems and obstetric services.
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Krumkamp R, Schwarz NG, Sarpong N, Loag W, Zeeb H, Adu-Sarkodie Y, May J. Extrapolating respiratory tract infection incidences to a rural area of Ghana using a probability model for hospital attendance. Int J Infect Dis 2012; 16:e429-35. [PMID: 22484157 DOI: 10.1016/j.ijid.2012.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 02/02/2012] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE The aim of the current study was to extrapolate incidences for respiratory tract infections (RTI) using referral data from a local hospital in Ghana weighted by the individual likelihood of a hospital visit. METHODS Diagnoses from children visiting a rural hospital in Ghana during August 2007 to September 2008 were recorded. A logistic regression model, based on a population study conducted within the hospital catchment area, was used to calculate the individual probability of clinic attendance and to extrapolate the number of recorded cases. Cumulative incidences for children living in the hospital catchment area were estimated. RESULTS Upper RTI was the most common respiratory diagnosis, with an extrapolated incidence of 17481 cases per 100000 per year, followed by pneumonia with an incidence of 2496 per 100 000 per year. All diseases analyzed were most common in the first year of life. CONCLUSIONS In general the study results are in line with comparable studies. Several methodological issues biasing the results in different directions were identified. For example, opportunistic infections that are more often observed in hospital attendees are likely to be overestimated. However, the applied approach presents a tool for areas where disease monitoring systems are not established.
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Affiliation(s)
- R Krumkamp
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.
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Baltag V, Filippi V, Bacci A. Putting theory into practice: the introduction of obstetric near-miss case reviews in the Republic of Moldova. Int J Qual Health Care 2012; 24:182-8. [PMID: 22215758 DOI: 10.1093/intqhc/mzr079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
QUALITY ISSUE The quality of obstetric services remains a major issue in the Republic of Moldova. Services are well staffed and intensively used but do not deliver the expected outputs. INITIAL ASSESSMENT Providers have limited experience with clinical audits and perceive them as a way to punish individuals. CHOICE OF SOLUTION Near-miss case reviews were introduced. Discussing near-miss cases might be less threatening to providers than discussing maternal deaths because the women survived. IMPLEMENTATION The quality of audits was evaluated against explicit criteria in three pilot maternities. EVALUATION On average one case was discussed every 5-6 weeks. Information from women's interviews was presented at all meetings, although the quality of the women's interviews was low. The weakest aspect of care was monitoring and follow-up treatment; the majority of proposed actions concerned the availability or compliance to protocols (52-69%). Proposed actions were consistent with prior analysis (95-100%), formulated in a clear and measurable way (58-90%), but the rate of failure to identify important actions was quite high in one facility (33%). Actions were more likely to be implemented when they concerned organization and management, drugs and supplies and least likely when they concerned staff. LESSONS LEARNED It is relatively easy to build capacity in organizing obstetric 'near-miss' audits, but more difficult to ensure that discussions are transposed into actions. In settings with no tradition of patients' involvement, increased attention should be given to providers' capacity to tackle patient-related factors.
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Affiliation(s)
- Valentina Baltag
- Making Pregnancy Safer Programme, World Health Organization Regional Office for Europe, Copenhagen Ø, Denmark.
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Raven J, Hofman J, Adegoke A, van den Broek N. Methodology and tools for quality improvement in maternal and newborn health care. Int J Gynaecol Obstet 2011; 114:4-9. [PMID: 21621681 DOI: 10.1016/j.ijgo.2011.02.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 02/16/2011] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To gain an overview of approaches, methodologies, and tools used in quality improvement of maternal and newborn health in low-income countries. METHODS Electronic search of MEDLINE and organizational databases for literature describing approaches, methodologies, and tools used to improve the quality of maternal and newborn health care in low-income countries. Relevant papers and reports were reviewed and summarized. RESULTS Developing a culture of quality is an important requisite for successful quality improvement. Methodologies to improve quality include the development of standards and guidelines and the performance of mortality, near-miss, and criterion-based audits. Tools for data collection and process description were identified, and examples of work to improve quality of care are provided. CONCLUSION The documented experience with the identified approaches, methodologies, and tools indicates that none is sufficient by itself to achieve a desirable improvement in quality of care. The choice of methodologies and tools depends on the healthcare system and its available resources. There is a lack of studies that describe the process of quality improvement and a need for research to provide evidence of the effectiveness of the identified methods and tools.
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Affiliation(s)
- Joanna Raven
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Liverpool, UK.
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Grimes CE, Bowman KG, Dodgion CM, Lavy CBD. Systematic Review of Barriers to Surgical Care in Low-Income and Middle-Income Countries. World J Surg 2011; 35:941-50. [DOI: 10.1007/s00268-011-1010-1] [Citation(s) in RCA: 253] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Exploring the sustainability of obstetric near-miss case reviews: a qualitative study in the South of Benin. Midwifery 2010; 26:537-43. [PMID: 20709433 DOI: 10.1016/j.midw.2010.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 05/11/2010] [Accepted: 05/24/2010] [Indexed: 11/20/2022]
Abstract
INTRODUCTION near-miss case reviews are one of a number of audit approaches currently being used and evaluated by those with an interest in reducing high rates of maternal mortality in developing countries. Researchers are beginning to take an interest in issues relating to the sustainability of audits. OBJECTIVE to develop an understanding of the barriers and facilitators to the sustainability of obstetric near-miss case reviews in five hospitals in southern Benin. DESIGN AND METHODS semi-structured interviews were designed to explore health workers' and policy makers' views and experiences of the sustainability of near-miss case reviews aimed to improve quality of care and reduce maternal mortality. SETTING five hospitals in three regions in the south of Benin. PARTICIPANTS two Ministry of Health officials and eight health-care workers involved in a feasibility study conducted in 1998-2001 that introduced near-miss case reviews. ANALYSIS framework analysis to identify themes. FINDINGS while all participants believed in the importance and value of audit, all hospitals had stopped performing near-miss case reviews within two years of completing the feasibility study. Ten qualitative interviews identified six themes relating to the sustainability of case reviews: clear advantages in ensuring quality of care, fear of blame and punishment, availability of resources, training, supportive hospital work environment, and broader policy issues. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE implementing and sustaining audit is a complex intervention that requires careful planning and consideration. It is important to consider both the content and the context in which audit takes place when developing strategies for sustainability.
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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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Olusanya BO, Solanke OA. Maternal and neonatal factors associated with mode of delivery under a universal newborn hearing screening programme in Lagos, Nigeria. BMC Pregnancy Childbirth 2009; 9:41. [PMID: 19732443 PMCID: PMC2749799 DOI: 10.1186/1471-2393-9-41] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Accepted: 09/04/2009] [Indexed: 11/10/2022] Open
Abstract
Background Emerging evidence from a recent pilot universal newborn hearing screening (UNHS) programme suggests that the burden of obstetric complications associated with mode of delivery is not limited to maternal and perinatal mortality but may also include outcomes that undermine optimal early childhood development of the surviving newborns. However, the potential pathways for this association have not been reported particularly in the context of a resource-poor setting. This study therefore set out to establish the pattern of delivery and the associated neonatal outcomes under a UNHS programme. Methods A cross-sectional study in which all consenting mothers who delivered in an inner-city tertiary maternity hospital in Lagos, Nigeria from May 2005 to December 2007 were enrolled during the UNHS programme. Socio-demographic, obstetric and neonatal factors independently associated with vaginal, elective and emergency caesarean deliveries were determined using multinomial logistic regression analyses. Results Of the 4615 mothers enrolled, 2584 (56.0%) deliveries were vaginal, 1590 (34.4%) emergency caesarean and 441 (9.6%) elective caesarean section. Maternal age, parity, social class and all obstetric factors including lack of antenatal care, maternal HIV and multiple gestations were associated with increased risk of emergency caesarean delivery compared with vaginal delivery. Only parity, lack of antenatal care and prolonged/obstructed labour were associated with increased risk of emergency compared with elective caesarean delivery. Infants delivered by vaginal method or by emergency caesarean section were more likely to be associated with the risk of sensorineural hearing loss but less likely to be associated with hyperbilirubinaemia compared with infants delivered by elective caesarean section. Emergency caesarean delivery was also associated with male gender, low five-minute Apgar scores and admission into special care baby unit compared with vaginal or elective caesarean delivery. Conclusions The vast majority of caesarean delivery in this population occur as emergencies and are associated with socio-demographic factors as well as several obstetric complications. Mode of delivery is also associated with the risk of sensorineural hearing loss and other adverse birth outcomes that lie on the causal pathways for potential developmental deficits.
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Affiliation(s)
- Bolajoko O Olusanya
- Maternal and Child Health Unit, Department of Community Health and Primary Care College of Medicine, University of Lagos, Surulere, Lagos, Nigeria.
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Rööst M, Jonsson C, Liljestrand J, Essén B. Social differentiation and embodied dispositions: a qualitative study of maternal care-seeking behaviour for near-miss morbidity in Bolivia. Reprod Health 2009; 6:13. [PMID: 19640286 PMCID: PMC2722580 DOI: 10.1186/1742-4755-6-13] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Accepted: 07/29/2009] [Indexed: 11/26/2022] Open
Abstract
Background Use of maternal health care in low-income countries has been associated with several socioeconomic and demographic factors, although contextual analyses of the latter have been few. A previous study showed that 75% of women with severe obstetric morbidity (near-miss) identified at hospitals in La Paz, Bolivia were in critical conditions upon arrival, underscoring the significance of pre-hospital barriers also in this setting with free and accessible maternal health care. The present study explores how health care-seeking behaviour for near-miss morbidity is conditioned in La Paz, Bolivia. Methods Thematic interviews with 30 women with a near-miss event upon arrival at hospital. Near-miss was defined based on clinical and management criteria. Modified analytic induction was applied in the analysis that was further influenced by theoretical views that care-seeking behaviour is formed by predisposing characteristics, enabling factors, and perceived need, as well as by socially shaped habitual behaviours. Results The self-perception of being fundamentally separated from "others", meaning those who utilise health care, was typical for women who customarily delivered at home and who delayed seeking medical assistance for obstetric emergencies. Other explanations given by these women were distrust of authority, mistreatment by staff, such as not being kept informed about their condition or the course of their treatment, all of which reinforced their dissociation from the health-care system. Conclusion The findings illustrate health care-seeking behaviour as a practise that is substantially conditioned by social differentiation. Social marginalization and the role health institutions play in shaping care-seeking behaviour have been de-emphasised by focusing solely on endogenous cultural factors in Bolivia.
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