Maternal death reviews at a rural hospital in Malawi

Health care providers’ knowledge of clinical protocols for postpartum hemorrhage care in Kenya: a cross-sectional study

Background

Postpartum hemorrhage (PPH) remains the leading cause of maternal death worldwide despite its often-preventable nature. Understanding health care providers’ knowledge of clinical protocols is imperative for improving quality of care and reducing mortality. This is especially pertinent in referral and teaching hospitals that train nursing and medical students and interns in addition to managing emergency and referral cases.

Methods

This study aimed to (1) measure health care providers’ knowledge of clinical protocols for risk assessment, prevention, and management of PPH in 3 referral hospitals in Kenya and (2) examine factors associated with providers’ knowledge. We developed a knowledge assessment tool based on past studies and clinical guidelines from the World Health Organization and the Kenyan Ministry of Health. We conducted in-person surveys with health care providers in three high-volume maternity facilities in Nairobi and western Kenya from October 2018-February 2019. We measured gaps in knowledge using a summative index and examined factors associated with knowledge (such as age, gender, qualification, experience, in-service training attendance, and a self-reported measure of peer-closeness) using linear regression.

Results

We interviewed 172 providers including consultants, medical officers, clinical officers, nurse-midwives, and students. Overall, knowledge was lowest for prevention-related protocols (an average of 0.71 out of 1.00; 95% CI 0.69–0.73) and highest for assessment-related protocols (0.81; 95% CI 0.79–0.83). Average knowledge scores did not differ significantly between qualified providers and students. Finally, we found that being a qualified nurse, having a specialization, being female, having a bachelor's degree and self-reported closer relationships with colleagues were statistically significantly associated with higher knowledge scores.

Conclusion

We found gaps in knowledge of PPH care clinical protocols in Kenya. There is a clear need for innovations in clinical training to ensure that providers in teaching referral hospitals are prepared to prevent, assess, and manage PPH. It is possible that training interventions focused on learning by doing and teamwork may be beneficial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05128-6.

Psychometric Assessment of the Breastfeeding Self-Efficacy Scale-Short Form: A Confirmatory Factor Analysis in Malawian Mothers

BACKGROUND

Exclusive breastfeeding to 6 months postpartum has been related to breastfeeding self-efficacy in diverse populations. Globally, this is measured using the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF).

RESEARCH AIM

To evaluate the psychometric properties of the BSES-SF among women in Malawi; and to examine the relationship between breastfeeding self-efficacy and demographic and health factors.

METHODS

The study design was a prospective, cross-sectional survey with a 2 week follow-up reliability check. Postpartum women (N = 180) were recruited at a maternity hospital in Lilongwe, Malawi. In addition to the BSES-SF, the World Health Organization's Quality of Life Scale (QoL) was also administered. Furthermore, confirmatory factor analysis, Cronbach's alpha, and Pearson's correlations were used to examine the construct validity, reliability, test-retest reliability, and convergent validity.

RESULTS

The confirmatory factor analysis supported a unidimensional structure of the Malawian version of the 12-item BSES-SF. Cronbach's alpha and the intra-class correlation coefficient were 0.79 and 0.75, respectively. BSES-SF scores had significant correlation with QoL domains (physical QoL: r = 0.31, p < .001; and environmental QoL: r = 0.22, p < .01). Participants' age, parity, and mode of delivery were positively correlated with breastfeeding self-efficacy scores.

CONCLUSION

The findings of our study confirmed that the 12-item BSES-SF is a reliable and valid scale for assessing women's breastfeeding self-efficacy in Malawi.

Know-do gaps in obstetric and newborn care quality in Uganda: a cross-sectional study in rural health facilities

OBJECTIVES

Variable and inadequate quality of maternity care is a critical factor in persistently high rates of maternal and neonatal mortality in Uganda. We investigated whether provider quality of care deviates from knowledge and the factors associated with these 'know-do gaps' in Ugandan maternity facilities.

METHODS

Data were collected from 109 providers in 40 facilities. Quality was measured using direct observations of intrapartum care, and scores were based on the percentage of essential care actions provided out of a 20-item validated quality index. Knowledge was measured based on the percentage of items that providers reported knowing to do using vignette surveys. The know-do gap was the difference between knowledge and quality. Multivariable models were used to assess the association between provider- and facility-level characteristics and knowledge, quality and know-do gaps.

RESULTS

The average quality score was 45%, with quality varying widely within and across providers. The mean knowledge score was 70%, yielding a mean know-do gap of 25%. Know-do gaps were largest for practices related to infection control, vitals monitoring, and prevention of postpartum haemorrhage. The association between quality and knowledge scores was positive but small (P = 0.08), so know-do gaps were largest for providers with the highest knowledge scores. Greater provider training was positively associated with knowledge (P = 0.005) but not with quality (P = 0.60). Having 10 or more years of work experience was associated with higher quality scores (5.3, 95%CI: 0.6 to 10.1), while higher patient volumes were associated with lower quality scores (-2.2, 95%CI: -3.7 to - 0.07). None of the factors of provider motivation, cadre, availability of essential medicines and supplies or facility staffing were associated with quality or know-do gaps.

CONCLUSIONS

Our results indicate that, in Uganda, gaps between knowledge and quality do not appear to be explained by factors such as lack of motivation, education, training or supplies. Gaps are particularly large for essential practices related to prevention of postpartum haemorrhage, a leading cause of maternal mortality in Uganda and similar settings.

Integrative Review of Factors That Affect the Use of Postpartum Care Services in Developing Countries

OBJECTIVE

To identify factors that affect the use of postpartum care services in developing countries.

DATA SOURCES

PubMed, CINAHL, Global Health, EMBASE, and grey literature were searched for relevant articles in 2015 and 2016 with no publication date limit imposed.

STUDY SELECTION

Thirteen studies met inclusion criteria and were assessed for quality with the use of a checklist developed by Fowkes and Fulton (1991) and a checklist developed by the Critical Appraisal Skills Programme (2017).

DATA EXTRACTION

The integrative review framework of Whittemore and Knafl (2005) guided the conduct of the review.

DATA SYNTHESIS

Results were synthesized based on the three delays model of Thaddeus and Maine (1994). Factors that negatively affected women's decisions to seek postpartum care (Phase I delays) included lack of women's autonomy, lack of exposure to mass media, no pregnancy/birth/postpartum complications, lack of awareness of postpartum care, negative provider attitude, lower levels of women's and husbands' education, women's and husbands' farming occupations, increasing number of children, and lower level of household income. Perceived easy access to a health care facility was associated with lesser odds of using postpartum care (Phase II delay). Hospitals, public health care facilities, and long queuing at a health care facility were associated with decreased postpartum care use (Phase III delays).

CONCLUSION

The most common determinants of how women used postpartum care were complications and the education levels and occupations of the women and their husbands. Further research is needed to identify health facility and accessibility factors that affect postpartum care use to develop effective interventions to improve the use of postpartum care.

Strengthening accountability for improved maternal and newborn health: A mapping of studies in Sub-Saharan Africa

OBJECTIVE

To describe the types of maternal and newborn health program accountability mechanisms implemented and evaluated in recent years in Sub-Saharan Africa, how these have been implemented, their effectiveness, and future prospects to improve governance and MNH outcomes.

METHOD

A structured review selected 38 peer-reviewed papers between 2006 and 2016 in Sub-Saharan Africa to include in the analysis.

RESULTS

Performance accountability in MNH through maternal and perinatal death surveillance was the most common accountability mechanism used. Political and democratic accountability through advocacy, human rights, and global tracking of progress on indicators achieved greatest results when multiple stakeholders were involved. Financial accountability can be effective but depend on external support. Overall, this review shows that accountability is more effective when clear expectations are backed by social and political advocacy and multistakeholder engagement, and supported by incentives for positive action.

CONCLUSION

There are few accountability mechanisms in MNH in Sub-Saharan Africa between decision-makers and those affected by those decisions with both the power and the will to enforce answerability. Increasing accountability depends not only on how mechanisms are enforced but also, on how providers and managers understand accountability.

Use of thermo-coagulation as an alternative treatment modality in a 'screen-and-treat' programme of cervical screening in rural Malawi

The incidence of cervical cancer in Malawi is the highest in the world and projected to increase in the absence of interventions. Although government policy supports screening using visual inspection with acetic acid (VIA), screening provision is limited due to lack of infrastructure, trained personnel, and the cost and availability of gas for cryotherapy. Recently, thermo‐coagulation has been acknowledged as a safe and acceptable procedure suitable for low‐resource settings. We introduced thermo‐coagulation for treatment of VIA‐positive lesions as an alternative to cryotherapy within a cervical screening service based on VIA, coupled with appropriate, sustainable pathways of care for women with high‐grade lesions and cancers. Detailed planning was undertaken for VIA clinics, and approvals were obtained from the Ministry of Health, Regional and Village Chiefs. Educational resources were developed. Thermo‐coagulators were introduced into hospital and health centre settings, with theoretical and practical training in safe use and maintenance of equipment. A total of 7,088 previously unscreened women attended VIA clinics between October 2013 and March 2015. Screening clinics were held daily in the hospital and weekly in the health centres. Overall, VIA positivity was 6.1%. Almost 90% received same day treatment in the hospital setting, and 3‐ to 6‐month cure rates of more than 90% are observed. Thermo‐coagulation proved feasible and acceptable in this setting. Effective implementation requires comprehensive training and provider support, ongoing competency assessment, quality assurance and improvement audit. Thermo‐coagulation offers an effective alternative to cryotherapy and encouraged VIA screening of many more women.

What's new?

Malawi has the highest incidence rates for cervical cancer worldwide, and a “screen‐and‐treat” program is in place to identify and treat precancerous lesions. Conventional cryotherapy is challenging as gas supply is inconsistent, cylinders are difficult to transport and running costs are high. Here, the authors introduce thermo‐coagulation as a treatment alternative, which proved feasible and acceptable in this resource‐poor setting and could increase the number of women receiving timely treatment for precancerous lesions in low‐ and middle‐income countries.

Maternal death reviews at Bugando hospital north-western Tanzania: a 2008-2012 retrospective analysis

BACKGROUND

Unacceptably high levels of maternal deaths still occur in many sub-Saharan countries and the health systems may not favour effective use of lessons from maternal death reviews to improve maternal survival. We report results from the analysis of data from maternal death reviews at Bugando Medical Centre north-western Tanzania in the period 2008-2012 and highlight the process, challenges and how the analysis provided a better understanding of maternal deaths.

METHODOLOGY

Retrospective analysis using maternal death review data and extraction of missing information from patients' files. Analysis was done in STATA statistical package into frequencies and means ± SD and median with 95% CI for categorical and numerical data respectively.

RESULTS

There were 80 deaths; mean age of the deceased 27.1 ± 6.2 years and a median hospital stay of 11.0 days [95% CI 11.0-15.3]. Most deaths were from direct obstetric causes (90); 60% from eclampsia, severe pre-eclampsia, sepsis, abortion and anaesthetic complications. Information on ANC attendance was recorded in 36.2% of the forms and gestation age of the pregnancy resulting into the death in 23.8%. Sixty one deaths (76.3%) occurred after delivery. The mode of delivery, place of delivery and delivery assistant were recorded in 44 (72.1), 38 (62.3) and 23 (37.7%) respectively.

CONCLUSION

Routine maternal death reviews in this setting do not involve comprehensive documentation of all relevant information, including actions taken to address some identified systemic weaknesses. Periodic analysis of available data may allow better understanding of vital information to improve the quality of maternity care.

Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi

BACKGROUND

In Malawi, maternal mortality remains high. Existing maternal death reviews fail to adequately review most deaths, or capture those that occur outside the health system. We assessed the value of community involvement to improve capture and response to community maternal deaths.

METHODS

We designed and piloted a community-linked maternal death review (CLMDR) process in Mchinji District, Malawi, which partnered community and health facility stakeholders to identify and review maternal deaths and generate actions to prevent future deaths. The CLMDR process involved five stages: community verbal autopsy, community and facility review meetings, a public meeting and bimonthly reviews involving both community and facility representatives.

RESULTS

The CLMDR process was found to be comparable to a previous research-driven surveillance system at identifying deaths in Mchinji District (population 456,500 in 2008). 52 maternal deaths were identified between July 2011 and June 2012, 27 (52%) of which would not have been identified without community involvement. Based on district estimates of population (500,000) and crude birth rate (35 births per 1000 population), the maternal mortality ratio was around 300 maternal deaths per 100,000 live births. Of the 41 cases that started the CLMDR process, 28 (68%) completed all five stages. We found the CLMDR process to increase the quantity of information available and to involve a wider range of stakeholders in maternal death review (MDR). The process resulted in high rates of completion of community-planned actions (82%), and district hospital (67%) and health centre (65%) actions to prevent maternal deaths.

CONCLUSIONS

CLMDR is an important addition to the established forms of MDR. It shows potential as a maternal death surveillance system, and may be applicable to similar contexts with high maternal mortality.

Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi

BACKGROUND

Shortages of staff have a significant and negative impact on maternal outcomes in low-income countries, but the impact on obstetric care providers in these contexts is less well documented. Despite the government of Malawi's efforts to increase the number of human resources for health, maternal mortality rates remain persistently high. Health workers' perceptions of insufficient staff or time to carry out their work can predict key variables concerning motivation and attrition, while the resulting sub-standard care and poor attitudes towards women dissuade women from facility-based delivery. Understanding the situation from the health worker perspective can inform policy options that may contribute to a better working environment for staff and improved quality of care for Malawi's women.

METHODS

A qualitative research design, using critical incident interviews, was used to generate a deep and textured understanding of participants' experiences. Eligible participants had performed at least one of the emergency obstetric care signal functions (a) in the previous three months and had experienced a demotivating critical incident within the same timeframe. Data were analysed using NVivo software.

RESULTS

Eighty-four interviews were conducted. Concerns about staff shortages and workload were key factors for over 40% of staff who stated their intention to leave their current post and for nearly two-thirds of the remaining health workers who were interviewed. The main themes emerging were: too few staff, too many patients; lack of clinical officers/doctors; inadequate obstetric skills; undermining performance and professionalism; and physical and psychological consequences for staff. Underlying factors were inflexible scheduling and staff allocations that made it impossible to deliver quality care.

CONCLUSION

This study revealed the difficult circumstances under which maternity staff are operating and the professional and emotional toll this exacts. Systems failures and inadequate human resource management are key contributors to the gaps in provision of obstetric care and need to be addressed. Thoughtful strategies that match supply to demand, coupled with targeted efforts to support health workers, are necessary to mitigate the effects of working in this context and to improve the quality of obstetric care for women in Malawi.

Maternal mortality in Malawi, 1977-2012

BACKGROUND

Millennium Development Goal 5 (MDG 5) targets a 75% reduction in maternal mortality from 1990 to 2015, yet accurate information on trends in maternal mortality and what drives them is sparse. We aimed to fill this gap for Malawi, a country in sub-Saharan Africa with high maternal mortality.

METHODS

We reviewed the literature for population-based studies that provide estimates of the maternal mortality ratio (MMR) in Malawi, and for studies that list and justify variables potentially associated with trends in MMR. We used all population-based estimates of MMR representative of the whole of Malawi to construct a best-fit trend-line for the range of years with available data, calculated the proportion attributable to HIV and qualitatively analysed trends and evidence related to other covariates to logically assess likely candidate drivers of the observed trend in MMR.

RESULTS

14 suitable estimates of MMR were found, covering the years 1977-2010. The resulting best-fit line predicted MMR in Malawi to have increased from 317 maternal deaths/100 000 live-births in 1980 to 748 in 1990, before peaking at 971 in 1999, and falling to 846 in 2005 and 484 in 2010. Concurrent deteriorations and improvements in HIV and health system investment and provisions are the most plausible explanations for the trend. Female literacy and education, family planning and poverty reduction could play more of a role if thresholds are passed in the coming years.

CONCLUSIONS

The decrease in MMR in Malawi is encouraging as it appears that recent efforts to control HIV and improve the health system are bearing fruit. Sustained efforts to prevent and treat maternal complications are required if Malawi is to attain the MDG 5 target and save the lives of more of its mothers in years to come.