Avoidable maternal mortality in Enugu, Nigeria

Impact of individual and environmental factors on academic performance of pregnant adolescent

BACKGROUND

Teenage pregnancies continue to disrupt teenage girls' academic development. As a result, teenage mothers are at risk of unemployment, maternal death, and poverty. Previous research, however, has shown that both individual and environmental factors can have a significant impact on the prevalence of adolescent pregnancy. However, there has been little rigorous research on the impact of these factors on pregnant students' academic performance.

OBJECTIVES

The purpose of this study was to determine the relationship between environmental (neighbourhood) and individuals (sexual attitudes, peer attachment) factors. It also examined the influence of individual factors on the academic performance of pregnant teens.

METHODS

The study included a cross-sectional study of 400 pregnant adolescent students aged 15-19 years. The target groups were drawn from three major cities in Nigeria. Respondents were identified through targeted snowballing. Pregnant participants were a combination of married and unmarried girls attending school from home. Data were collected using a structured and self-completed questionnaire. Thus, frequency, mean and standard deviation were used for descriptive analysis. Pearson correlation analysis was applied to show the relationship between variables.

RESULTS

The study found that neighbourhood (r=-.125, p = .12) had a negative and significant relationship with peer attachment. However, there was no significant evidence of a relationship between sexual attitudes and neighbourhood (r=-.040, p = .422). There was, however, a significant relationship between sexual attitudes and academic performance (r = .236, p = .000). There was also a relationship between peer attachment and academic performance (r=-.401, p = < 0.001).

CONCLUSION

This study suggests that the academic performance of pregnant teenagers necessitates a combination of approaches, which includes changes in personal and prosocial behaviour, and environmental reforms. This can be achieved through, peer education, school day-care, subsidised or free contraceptives, free or subsidized education, and community programmes that positively influence young adults in the neighbourhood. These approaches can indirectly boost self-efficacy, motivation, and confidence to achieve higher academic feat, while reducing school dropout rate among the target groups.

Individual, health facility and wider health system factors contributing to maternal deaths in Africa: A scoping review

The number of women dying during pregnancy and after childbirth remains unacceptably high, with African countries showing the slowest decline. The leading causes of maternal deaths in Africa are preventable direct obstetric causes such as haemorrhage, infection, hypertension, unsafe abortion, and obstructed labour. There is an information gap on factors contributing to maternal deaths in Africa. Our objective was to identify these contributing factors and assess the frequency of their reporting in published literature. We followed the Arksey and O'Malley methodological framework for scoping reviews. We searched six electronic bibliographic databases: MEDLINE, SCOPUS, African Index Medicus, African Journals Online (AJOL), French humanities and social sciences databases, and Web of Science. We included articles published between 1987 and 2021 without language restriction. Our conceptual framework was informed by a combination of the socio-ecological model, the three delays conceptual framework for analysing the determinants of maternal mortality and the signal functions of emergency obstetric care. We included 104 articles from 27 African countries. The most frequently reported contributory factors by level were: (1) Individual-level: Delay in deciding to seek help and in recognition of danger signs (37.5% of articles), (2) Health facility-level: Suboptimal service delivery relating to triage, monitoring, and referral (80.8% of articles) and (3) Wider health system-level: Transport to and between health facilities (84.6% of articles). Our findings indicate that health facility-level factors were the most frequently reported contributing factors to maternal deaths in Africa. There is a lack of data from some African countries, especially those countries with armed conflict currently or in the recent past. Information gaps exist in the following areas: Statistical significance of each contributing factor and whether contributing factors alone adequately explain the variations in maternal mortality ratios (MMR) seen between countries and at sub-national levels.

Maternal mortality ratio in Jiangsu Province, China: recent trends and associated factors

BACKGROUND

In recent years, births to older mothers and multiparous mothers have increased rapidly with the change of birth policy in China. And mothers of advanced age are more likely to have maternal complications and poor birth outcomes. We aimed to estimate the recent trends and underlying risk factors of maternal mortality.

METHODS

In this systematic assessment, we used data from the National Maternal and Child Health Routine Reporting System (2013-2018), Jiangsu Provincial Maternal Mortality Surveillance System (2017-2018), the Integrated National Mortality Surveillance System (2018), City Statistical Yearbooks (2018), City Health Statistical Yearbooks (2018). The factors associated with maternal mortality ratio (MMR) were explored using the stepwise regression analysis and cluster analysis.

RESULTS

The MMR maintained at low levels between 2013 and 2016 and there was a slight increase in maternal mortality after 2016 in Jiangsu province. With the implementation of the China's universal two child policies, the percentage of multiparous mothers ascended from 34.2% (95% confidence interval (CI) = 34.1-34.3%) in 2013 to 51.4% (95% CI = 51.3-51.6%) in 2018 (beta = 3.88, P < 0.001). Consistently, the percentage of advanced maternal age (≥ 35) increased from 8.4% (95% CI = 8.4-8.5%) in 2013 to 10.4% (95% CI = 10.3-10.4%) in 2018 (beta = 0.50, P = 0.012). And we found that the percentage of multiparous mothers and advanced maternal age among maternal deaths were higher than all pregnant women (P < 0.001). In the stepwise regression analysis, four risk factors were significantly associated with maternal mortality ratio (primary industry of gross domestic product (GDP), rate of delivery in maternal and child health hospital, rate of cesarean section and rate of low birth weight). As the results derived from cluster analysis, the relatively developed regions had lower preventable maternal mortality ratio (43.5% (95% CI = 31.2-56.7%) vs. 62.6% (95% CI = 52.3-72.0%), P = 0.027).

CONCLUSIONS

Since the universal two child policy has been associated with changes in health related birth characteristics: women giving birth have been more likely to be multiparous, and more likely to be aged 35 and over. This somewhat magnifies the impact of differences in economic development and obstetric services on MMR. The findings based on prefecture level data suggest that interventions must target economic development, the health system and maternal risk factors in synergy. These approaches will be of great benefit to control or diminish environmental factors associated with preventable deaths and will effectively reduce MMR and narrow the gap among the different regions.

Teamwork, Professional Identities, Conflict, and Industrial Action in Nigerian Healthcare

PURPOSE

Modern healthcare is delivered by teams of multidisciplinary professionals. Conflicts have been widely reported between these professionals in Nigeria. Furthermore, the health system is frequently crippled by industrial actions by trade unions representing these professionals. This study aimed to shed light on the complexities of factors perceived to cause workplace conflicts, including the extent to which these are thought to link to industrial action.

MATERIALS AND METHODS

Focus group discussions and in-depth interviews were conducted with nurses, doctors, and medical laboratory scientists who work in multiprofessional settings giving a total of 41 participants. Results were analyzed within the framework of the social identity theory.

RESULTS AND CONCLUSIONS

The dominant themes that emerged as barriers to teamwork include professional hierarchy, role ambiguity, and poor communication. At the same time, the health sector leadership and remuneration were the main themes concerning industrial actions. The salience of professional identities was also demonstrated, providing a link between interprofessional conflict in the workplace and competitive industrial actions by trade unions representing health professionals. The implications for educational and clinical practice and the need for interprofessional education are discussed.

A Comparison of the Characteristics of Maternal Near-Misses and Maternal Deaths in Enugu, Southeast Nigeria: A 3-Year Prospective Study

BACKGROUND

Maternal near-misses, also known as severe acute maternal morbidity, have become globally recognized as an appropriate indicator of obstetric care. Women experiencing maternal near-misses are more in number than maternal deaths, and can provide more specific and detailed evidence, as the patient herself can be a leading source of useful information.

OBJECTIVE

To determine the frequency of maternal near-misses and maternal deaths in the University of Nigeria Teaching Hospital in Ituku-Ozalla, Enugu, document the primary determinant factor that caused these, and compare cases of maternal near-miss and maternal deaths.

METHODS

This was a 3-year prospective study of all women admitted for delivery or within 42 days of delivery or termination of pregnancy at the hospital. Data were collected prospectively in consecutive patients in a pro forma manner and entered into SPSS version 17 for Windows.

RESULTS

There was a total of 2,236 deliveries, of which 88 had severe maternal outcomes. Of the latter, 60 were maternal near-misses, while 28 suffered maternal death. The maternal near-miss:mortality ratio was found to be 2.14. The maternal mortality ratio here was 1,252 per 100,000. All the 88 women that had severe maternal outcomes lived at least 5 km from the hospital. The leading organ-system dysfunction in this study was cardiovascular, manifesting as shock and cardiac arrest, and respiratory, manifesting as gasping and cyanosis. Leading complications were severe hemorrhage, anemia, and hypertensive disorders. The pattern of complications was similar in both near-misses and maternal deaths, but cases of hypertensive disorders and exploratory laparotomy as an intervention for those with organ dysfunction were noted to be higher in near-miss cases, and differences were statistically significant.

CONCLUSION

It was concluded that despite numerous similarities in the characteristics of patients who had had maternal near-misses or died, our study points out that those who succumb to death are often <40 years of age, poorly educated, unemployed, usually present as unbooked emergencies from a distance >5 km and suffer maternal death within 24 hours of presentation.

Maternal near-miss and death among women with hypertensive disorders in pregnancy: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey

OBJECTIVE

To investigate life-threatening maternal complications related to hypertensive disorders of pregnancy (HDP) in Nigerian public tertiary hospitals.

DESIGN

Secondary analysis of a nationwide cross-sectional study.

SETTING

Forty-two tertiary hospitals.

POPULATION

Women admitted for pregnancy, childbirth or puerperal complications.

METHOD

All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) due to HDP were prospectively identified using the WHO criteria over a 1-year period.

MAIN OUTCOME MEASURES

Incidence of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).

RESULTS

Out of 100 107 admissions for maternal complications, 6753 (6.8%) women had HDP. Pre-eclampsia (PE) (54.5%) and eclampsia (E) (30.4%) were the most common HDP recorded. SMO occurred in 587 women with HDP: 298 maternal near-misses and 289 maternal deaths. The majority (93%) of the women with SMO due to HDP were admitted in a critical condition. The median diagnosis-definitive intervention interval was over 4 hours in a quarter of women who died from HDP. For PE and E, case fatality rates were 1.9 and 10.4%, respectively, although both conditions had a similar mortality index of 49.3%. Lack of antenatal care and place of residence further than 5 km from the hospital were associated with maternal death.

CONCLUSIONS

Severe maternal outcomes from HDP were due to late presentations and health system challenges. To reduce maternal deaths from HDP, health system strengthening that would engender early hospital presentation and prompt treatment is recommended.

FUNDING

The original research that generated the data for this secondary analysis was funded by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization (WHO). We have no other funding issue to declare for our study.

TWEETABLE ABSTRACT

Eclampsia is the leading cause of maternal death in Nigerian hospitals.

Generating evidence for health policy in challenging settings: lessons learned from four prevention of mother-to-child transmission of HIV implementation research studies in Nigeria

BACKGROUND

Implementation research (IR) facilitates health systems strengthening and optimal patient outcomes by generating evidence for scale-up of efficacious strategies in context. Thus, difficulties in generating IR evidence, particularly in limited-resource settings with wide disease prevention and treatment gaps, need to be anticipated and addressed. Nigeria is a priority country for the prevention of mother-to-child transmission of HIV (PMTCT). This paper analyses the experiences of four PMTCT IR studies in Nigeria, and proffers solutions to major challenges encountered during implementation.

STUDIES INCLUDED AND FINDINGS

Multicentre PMTCT IR studies conducted in Nigeria during the Global Plan's assessment period (2011 to 2015) were included. Four studies were identified, namely The Baby Shower Trial, Optimizing PMTCT, MoMent and Lafiyan Jikin Mata. Major common challenges encountered were categorised as 'External' (beyond the control of study teams) and 'Internal' (amenable to rectification by study teams). External challenges included healthcare worker strikes and turnover, acts and threats of ethnic and political violence and terrorism, and multiplicity of required local ethical reviews. Internal challenges included limited research capacity among study staff, research staff turnover and travel restrictions hindering study site visits. Deliberate research capacity-building was provided to study staff through multiple opportunities before and during study implementation. Post-study employment opportunities and pathways for further research career-building are suggested as incentives for study staff retention. Engagement of study community-resident personnel minimised research staff turnover in violence-prone areas.

CONCLUSIONS

The IR environment in Nigeria is extremely diverse and challenging, yet, with local experience and anticipatory planning, innovative solutions can be implemented to modulate internal challenges. Issues still remain with healthcare worker strikes and often unpredictable insecurity. There is a dire need for cooperation between institutional review boards across Nigeria in order to minimise the multiplicity of reviews for multicentre studies. External challenges need to be addressed by high-level stakeholders, given Nigeria's crucial regional and global position in the fight against the HIV epidemic.

Maternal and fetal outcomes of emergency obstetric referrals to a Nigerian teaching hospital

Our study sought to determine the maternal and fetal outcomes of emergency obstetric referrals to a Nigerian teaching hospital as well as assess reasons for these referrals. We enrolled women referred or who presented themselves to the emergency obstetric unit for management of complications of pregnancy, labour, delivery or the puerperium. The majority presented late, their mean duration of stay at the referring facility being 22.25 h. Only nine (7.3%) were transported by ambulance. Severe pre-eclampsia and eclampsia (in 33, 26.8%) were the commonest obstetric indications for referral. Stillbirths occurred in 20/122(16.4%). There were eleven maternal deaths, giving an emergency referral fatality rate of 8.9%. Both maternal and fetal outcomes of these emergency obstetric referrals were poor owing mainly to late presentation, this being the result, among other factors, of an inefficient referral system.

Maternal death and obstetric care audits in Nigeria: a systematic review of barriers and enabling factors in the provision of emergency care

Background

Maternal death reviews and obstetric audits identify causes and circumstances related to occurrence of a maternal death or serious complication and inform improvements in quality of care. Given Nigeria’s high maternal mortality, the lessons learned from past experiences can provide a good evidence base for informed decision making. We aimed to synthesise findings from maternal death reviews and other obstetric audits conducted in Nigeria through a systematic review, seeking to identify common barriers and enabling factors related to the provision of emergency obstetric care.

Methods

We searched for maternal death reviews and obstetric care audits reported in the published literature from 2000–2014. A ‘best-fit’ framework approach was used to extract data using a structured data extraction form. The articles that met the inclusion criteria were assessed using a nine point quality score.

Results

Of the 1,841 abstracts and titles at initial screening, 329 full text articles were reviewed and 43 papers fulfilled the inclusion criteria. Four types of barriers were reported related to: transport and referral; health workers; availability of services; and organisational factors. Three elements stand out in Nigeria as contributing to maternal mortality: delays in Caesarean section, unavailability of magnesium sulphate and lack of safe blood transfusion services.

Conclusions

Obstetric care reviews and audits are useful activities to undertake and should be promoted by improving the processes used to conduct them, as well as extending their implementation to rural and basic level health facilities and to the community. Urgent areas for quality improvement in obstetric care, even in tertiary and teaching hospitals should focus on organisational factors to reduce delays in conducting Caesarean section and making blood and magnesium sulphate available for all who need these interventions.

Maternal mortality and accessibility to health services by means of transit-network estimated traveled distances

This study analyzed the relationship between maternal mortality and variables related to the use of health services (especially residence-hospital traveled distances estimated through transit networks). Deaths were identified for Rio de Janeiro and adjacent cities, from 2000 to 2002, and were matched by age and socio-economic level to birth admissions without maternal deaths (1 case to 3 controls). The variables used were: type of hospital (general × specialized maternity services), number of hospital beds, nature of hospital ownership (public × private-associated), main admission diagnostic, residence-hospital distance, age, income, and education. Distances were estimated by a geographic information system, and were based on most probable itineraries through the urban transit networks. The probability of death was estimated by conditional logistic regression models. 226 maternal deaths were studied, and another 10 were excluded due to incompleteness of information. The ROC area for the final model was 0.89 [95% CI (0.87-0.92)]. This model retained statistical significance for the variables admission diagnostic, type of hospital and residence-hospital distance. The death odds ratio for women who traveled 5-10 km (reference category: <5 km) was 3.84 [95% CI (1.96-7.55)]. The traveled distance measured through transit networks was an important risk factor for death in the studied population.

A case-control study of risk factors for fetal and early neonatal deaths in a tertiary hospital in Kenya

BACKGROUND

It is important to understand the risk factors for fetal and neonatal mortality which is a major contributor to high under five deaths globally. Fetal and neonatal mortality is a sensitive indicator of maternal health in society. This study aimed to examine the risk factors for fetal and early neonatal mortality at the Moi Teaching and Referral Hospital in Kenya.

METHODS

This was a case-control study. Cases were fetal and early neonatal deaths (n = 200). The controls were infants born alive immediately preceding and following the cases (n = 400). Bivariate comparisons and multiple logistic regression analyses were undertaken.

RESULTS

The odds of having 0-1 antenatal visits relative to 2-3 visits were higher for cases than controls (Adjusted Odds Ratio (AOR) = 4.5; 95% CI: 1.2-16.7; p = 0.03)). There were lower odds among cases of having a doctor rather than a midwife as a birth attendant (AOR = 0.2; 95% CI: 0.1-0.6; p < 0.01). The odds of mothers having Premature Rupture of Membranes (AOR = 4.1; 95% CI: 1.4-12.1; p = 0.01), haemorrhage (AOR = 4.8; 95% CI: 1.1-21.9; p = 0.04) and dystocia (AOR = 3.6; 95% CI: 1.2-10.9; p = 0.02) were higher for the cases compared with the controls. The odds of gestational age less than 37 weeks (AOR = 7.0; 95% CI 2.4-20.4) and above 42 weeks (AOR = 16.2; 95% CI 2.8-92.3) compared to 37-42 weeks, were higher for cases relative to controls (p < 0.01). Cases had higher odds of being born with congenital malformations (AOR = 6.3; 95% CI: 1.2-31.6; p = 0.04) and with Apgar scores of below six at five minutes (AOR = 26.4; 95% CI: 6.1-113.8; p < 0.001).

CONCLUSION

Interventions that focus on educating mothers on antenatal attendance, screening, monitoring and management of maternal conditions during the antenatal period should be strengthened. Doctor attendance at each birth and for emergency admissions is important to ensure early neonatal survival and avert potential risk factors for mortality.

Maternal mortality at Muhimbili National Hospital in Dar-es-Salaam, Tanzania in the year 2011

BACKGROUND

Improving maternal health is one of the eight millennium development goals adopted at the millennium summit in the year 2000. Within this frame work, the international community is committed to reduce the maternal mortality ratio by 75% between 1990 and 2015. The objective of this study was to determine the maternal mortality ratio, classify causes of maternal deaths and assess substandard care factors at Muhimbili National Hospital (MNH), Dar-es-Salaam in Tanzania.

METHODS

A retrospective review of all maternal death records of cases that occurred from 1st January to 31st December 2011 was done.

RESULTS

There were 10,057 live births, 155 maternal deaths and hence MMR of 1,541 per 100,000 live births. Direct causes of maternal deaths were classified in 69.5% of the maternal deaths. Of the direct causes, preeclampsia/eclampsia was the major cause (19.9% of all deaths), followed by post partum haemorrhage (14.9%), abortion complications (9.9%) and sepsis (9.2%). Among the indirect causes anaemia was the leading cause (11.3%) of all deaths, followed by HIV/AIDS (9.9%). Substandard care factors contributing to deaths were identified in 116 (82.3%) of all cases. Among these 28 had patient factors only, 71 medical service factors while 17 had both patient and medical service substandard care factors. The common factors from the woman's side included delay in seeking care (73.3%) and complete lack of antenatal care (11.1%). Of the medical service factors, inadequate (26.1%) or no blood for transfusion (19.3%), delay in receiving treatment (18.3%) and mismanagement (17%) were the common factors.

CONCLUSION

There is a high maternal mortality ratio at MNH. Hypertensive disorders of pregnancy, post partum haemorrhage and anaemia are the leading causes of maternal deaths in this institution. Multiple substandard care factors identified both at individual and health care service levels that contributed to maternal deaths. There is a need for increasing efforts in the fight to reduce maternal deaths at the institution. A more pro-active role from the referring facilities in the region is needed.

Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review

BACKGROUND

Audits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries.

METHODS

We performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews.

RESULTS

Thirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified.

CONCLUSIONS

Audits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five.

Quality improvement in emergency obstetric referrals: qualitative study of provider perspectives in Assin North District, Ghana

OBJECTIVE

To describe healthcare worker (HCW)-identified system-based bottlenecks and the value of local engagement in designing strategies to improve referral processes related to emergency obstetric care in rural Ghana.

DESIGN

Qualitative study using semistructured interviews of participants to obtain provider narratives.

SETTING

Referral systems in obstetrics in Assin North Municipal Assembly, a rural district in Ghana. This included one district hospital, six health centres and four local health posts. This work was embedded in an ongoing quality improvement project in the district addressing barriers to existing referral protocols to lessen delays.

PARTICIPANTS

18 HCWs (8 midwives, 4 community health officers, 3 medical assistants, 2 emergency room nurses, 1 doctor) at different facility levels within the district.

RESULTS

We identified important gaps in referral processes in Assin North, with the most commonly noted including recognising danger signs, alerting receiving units, accompanying critically ill patients, documenting referral cases and giving and obtaining feedback on referred cases. Main root causes identified by providers were in four domains: (1) transportation, (2) communication, (3) clinical skills and management and (4) standards of care and monitoring, and suggested interventions that target these barriers. Mapping these challenges allowed for better understanding of next steps for developing comprehensive, evidence-based solutions to identified referral gaps within the district.

CONCLUSIONS

Providers are an important source of information on local referral delays and in the development of approaches to improvement responsive to these gaps. Better engagement of HCWs can help to identify and evaluate high-impact holistic interventions to address faulty referral systems which result in poor maternal outcomes in resource-poor settings. These perspectives need to be integrated with patient and community perspectives.

Risk factors for maternal mortality in a Tertiary Hospital in Kenya: a case control study

Background

Maternal mortality is high in Africa, especially in Kenya where there is evidence of insufficient progress towards Millennium Development Goal (MDG) Five, which is to reduce the global maternal mortality rate by three quarters and provide universal access to reproductive health by 2015. This study aims to identify risk factors associated with maternal mortality in a tertiary level hospital in Kenya.

Methods

A manual review of records for 150 maternal deaths (cases) and 300 controls was undertaken using a standard audit form. The sample included pregnant women aged 15-49 years admitted to the Obstetric and Gynaecological wards at the Moi Teaching and Referral Hospital (MTRH) in Kenya from January 2004 and March 2011. Logistic regression analysis was used to assess risk factors for maternal mortality.

Results

Factors significantly associated with maternal mortality included: having no education relative to secondary education (OR 3.3, 95% CI 1.1-10.4, p = 0.0284), history of underlying medical conditions (OR 3.9, 95% CI 1.7-9.2, p = 0.0016), doctor attendance at birth (OR 4.6, 95% CI 2.1-10.1, p = 0.0001), having no antenatal visits (OR 4.1, 95% CI 1.6-10.4, p = 0.0007), being admitted with eclampsia (OR 10.9, 95% CI 3.7-31.9, p < 0.0001), being admitted with comorbidities (OR 9.0, 95% CI 4.2-19.3, p < 0.0001), having an elevated pulse on admission (OR 10.7, 95% CI 2.7-43.4, p = 0.0002), and being referred to MTRH (OR 2.1, 95% CI 1.0-4.3, p = 0.0459).

Conclusions

Antenatal care and maternal education are important risk factors for maternal mortality, even after adjusting for comorbidities and complications. Antenatal visits can provide opportunities for detecting risk factors for eclampsia, and other underlying illnesses but the visits need to be frequent and timely. Education enables access to information and helps empower women and their spouses to make appropriate decisions during pregnancy.

When women deliver with no one present in Nigeria: who, what, where and so what?

With the current maternal mortality ratio (MMR) of 630/100,000 live births, Nigeria ranks among the nations with the highest mortality rates in the world. The use of skilled assistants during delivery has been identified a key predictor in the reduction of mortality rates in the world over. Not only are Nigerian women predominantly using unskilled attendants, one in five births are delivered with No One Present (NOP). We assessed who, what, where and the so what of this practice using 2008 Nigeria DHS (NDHS) data. The study revealed that the prevalence of NOP is highest in the northern part of Nigeria with 94% of all observed cases. Socio-demographic factors, including, women's age at birth, birth order, being Muslim, and region of residence, were positively associated with NOP deliveries. Mother's education, higher wealth quintiles, urban residence, decision-making autonomy, and a supportive environment for women's social and economic security were inversely associated with NOP deliveries. Women's autonomy and social standing were critical to choosing to deliver with skilled attendance, which were further amplified by economic prosperity. Women's' economic wellbeing is entwined with their feelings of independence and freedom. Programs that seek to improve the autonomy of women and their strategic participation in sound health seeking decisions will, most likely, yield better results with improvements in women's education, income, jobs, and property ownership. As a short term measure, the use of conditional cash transfer, proven to work in several countries, including 18 in sub-Saharan Africa, is recommended. Its use has the potential to reduce household budget constraint by lowering cost-related barriers associated with women's ability to demand and use life-saving services. Given the preponderance of NOP in the Northern region, the study suggests that interventions to eradicate NOP deliveries must initially focus this region as priority.

Preventable maternal mortality in Morocco: the role of hospitals

OBJECTIVE

In 2009, the Ministry of Health of Morocco launched a national confidential enquiry around maternal deaths based on the newly implemented routine maternal death surveillance system (MDSS). The objective of this paper is to show the importance of substandard care among the factors associated with maternal deaths.

METHODS

The Moroccan National Expert Committee (NEC) organised an audit of maternal deaths identified by the MDSS to determine the medical cause, the preventability of the deaths and the type of substandard care involved.

RESULTS

Three hundred and three cases of maternal deaths were analysed for the year 2009. Direct causes accounted for 80.8%. 75.9% were considered avoidable by the NEC. The three main factors were insufficient follow-up of care in 45.6% of cases, inadequate treatment in 43.9% and delay in seeking care in 41.3%. The auditors found that 54.3% of all maternal deaths could have been avoided if appropriate action had been taken at the health facilities.

CONCLUSION

The audit of maternal deaths in Morocco enabled a better understanding of the circumstances contributing to maternal deaths and pinpointed that more than half of maternal deaths were associated with substandard care in hospitals.

Client education experiences and expectations of women at the first level of maternal and child care in Kaduna state, Nigeria

PURPOSE

to explore the client education experiences of women at first level maternal and child health-care facilities in Kaduna State Nigeria. The lack of access to appropriate information to assist women in making decisions about their health and utilize available services is recognized as a major contributory factor to the unabated high maternal and child mortality rates in Nigeria.

DESIGN

a qualitative descriptive study was conducted. Nine focus group discussions were held with 65 women across the three senatorial zones of Kaduna State, Nigeria. Participants were recruited using maximum variation sampling technique. Audio recordings of the discussions were transcribed and the content analysed. The themes were determined by a priory approach and findings compared across groups through manually developed data matrices.

FINDINGS

midwives were the major source of useful health information to the women who wished the midwives could cover more issues. The information provided by the midwives was skewed towards children and postnatal care, and some midwives ignored, or considered some of the women's questions interrupting. The harshness of midwives in emphasizing the need for prompt care, to women who came late to register or deliver, kept some women away. Women who never delivered in the facilities were not aware that the 'nurses' at the clinics were midwives, and desired to know more about midwifery in the facilities being tired of traditional birth attendants.

CONCLUSION

the desire of women for more information and to know the 'midwife' suggests a gap between what the women expected and what they were provided.

IMPLICATION FOR PRACTICE

it is important to expand the scope of client education to include critical pregnancy and labour related issues and friendly midwifery practices in the facility.

Male responsibility and maternal morbidity: a cross-sectional study in two Nigerian states

Background

Nigeria continues to have high rates of maternal morbidity and mortality. This is partly associated with lack of adequate obstetric care, partly with high risks in pregnancy, including heavy work. We examined actionable risk factors and underlying determinants at community level in Bauchi and Cross River States of Nigeria, including several related to male responsibility in pregnancy.

Method

In 2009, field teams visited a stratified (urban/rural) last stage random sample of 180 enumeration areas drawn from the most recent censuses in each of Bauchi and Cross River states. A structured questionnaire administered in face-to-face interviews with women aged 15-49 years documented education, income, recent birth history, knowledge and attitudes related to safe birth, and deliveries in the last three years. Closed questions covered female genital mutilation, intimate partner violence (IPV) in the last year, IPV during the last pregnancy, work during the last pregnancy, and support during pregnancy. The outcome was complications in pregnancy and delivery (eclampsia, sepsis, bleeding) among survivors of childbirth in the last three years. We adjusted bivariate and multivariate analysis for clustering.

Findings

The most consistent and prominent of 28 candidate risk factors and underlying determinants for non-fatal maternal morbidity was intimate partner violence (IPV) during pregnancy (ORa 2.15, 95%CIca 1.43-3.24 in Bauchi and ORa 1.5, 95%CI 1.20-2.03 in Cross River). Other spouse-related factors in the multivariate model included not discussing pregnancy with the spouse and, independently, IPV in the last year. Shortage of food in the last week was a factor in both Bauchi (ORa 1.66, 95%CIca 1.22-2.26) and Cross River (ORa 1.32, 95%CIca 1.15-1.53). Female genital mutilation was a factor among less well to do Bauchi women (ORa 2.1, 95%CIca 1.39-3.17) and all Cross River women (ORa 1.23, 95%CIca 1.1-1.5).

Interpretation

Enhancing clinical protocols and skills can only benefit women in Nigeria and elsewhere. But the violence women experience throughout their lives – genital mutilation, domestic violence, and steep power gradients – is accentuated through pregnancy and childbirth, when women are most vulnerable. IPV especially in pregnancy, women's fear of husbands or partners and not discussing pregnancy are all within men's capacity to change.

Preventable maternal mortality: geographic/rural-urban differences and associated factors from the population-based Maternal Mortality Surveillance System in China

BACKGROUND

Most maternal deaths in developing countries can be prevented. China is among the 13 countries with the most maternal deaths; however, there has been a marked decrease in the maternal mortality ratio (MMR) over the last 3 decades. China's reduction in the MMR has contributed significantly to the global decline of the MMR. This study examined the geographic and rural-urban differences, time trends and related factors in preventable maternal deaths in China during 1996-2005, with the aim of providing reliable evidence for effective interventions.

METHODS

Data were retrieved from the population-based maternal mortality surveillance system in China. Each death was reviewed by three committees to determine whether it was avoidable. The preventable maternal mortality ratio (PMMR), the ratios of PMMR (risk ratio, RR) and 95% confidence intervals (CI) were used to analyze regional disparities (coastal, inland and remote regions) and rural-urban variations. Time trends in the MMR, along with underlying causes and associated factors of death, were also analysed.

RESULTS

Overall, 86.1% of maternal mortality was preventable. The RR of preventable maternal mortality adjusted by region was 2.79 (95% CI 2.42-3.21) and 2.38 (95% CI: 2.01-2.81) in rural areas compared to urban areas during the 1996-2000 and 2001-2005 periods, respectively. Meanwhile, the RR was the highest in remote areas, which was 4.80(95%CI: 4.10-5.61) and 4.74(95%CI: 3.86-5.83) times as much as that of coastal areas. Obstetric haemorrhage accounted for over 50% of preventable deaths during the 2001-2005 period. Insufficient information about pregnancy among women in remote areas and out-of-date knowledge and skills of health professionals and substandard obstetric services in coastal regions were the factors frequently associated with MMR.

CONCLUSIONS

Preventable maternal mortality and the distribution of its associated factors in China revealed obvious regional differences. The PMMR was higher in underdeveloped regions. In future interventions in remote and inland areas, more emphasis should be placed on improving women's ability to utilize healthcare services, enhancing the service capability of health institutions, and increasing the accessibility of obstetric services. These approaches will effectively lower PMMR in those regions and narrow the gap among the different regions.

A training need for rural primary care in Nigeria

The major causes of maternal death in Nigeria are avoidable and preventable. Many of these deaths occur in the rural health facilities and hospitals which are severely lacking in skilled birth attendants. Of the many strategies that have been developed to reduce avoidable maternal death significantly, increasing the availability of skilled human resources is crucial. The shortage of obstetric specialists, especially in the rural and peripheral health facilities in rural Nigeria where more than 60% of the population resides, has been a major contributing factor to the low number of skilled birth attendants. The increased availability of skilled human resources ensures that all aspects of obstetrics, such as antenatal care, postnatal care and other life-saving interventions, including emergency surgery, is available for women during labour and in the immediate postpartum period. In this paper, we propose a short obstetric-training programme for generalist medical officers to increase the number of skilled birth attendants in both rural and peripheral health facilities in Nigeria. These general practice/family practitioners (GP/FPs) and hospital medical officers (MO), will have designated career structures within the primary and secondary healthcare systems, while the consultant obstetrician and sub-specialists, trained with long postgraduate programmes will function at the urban 'specialists' and in teaching hospitals.

Multiple antenatal bookings among pregnant women in Enugu, Nigeria

Some pregnant women do book concurrently with multiple antenatal care providers. Structured questionnaires were administered to women attending antenatal clinics in 12 facilities in Enugu, Nigeria. A total of 535 women responded: 372 (69.5%) were booked into more than one facility and 163 (30.5%) were booked into a single facility; 280 (52.3%) booked into the two Teaching Hospitals and 91 (12.5%) booked with a traditional birth attendant. Reasons for multiple bookings included selecting a facility with affordable prices (43.9%); selecting a facility promising vaginal delivery (35.3%); avoiding HIV testing (17.9%); avoiding caesarean section (10.8%); avoiding being regarded as unbooked (10.1%) and booking into a facility where they were not known. Possible disadvantages were confusion in deciding where to deliver (53.1%); default on expert advice (27.5%); mismanagement (18.7%); delays, complications and death (12.5%). Multiple bookings were common in this study. Disadvantages of this practice, including risk of death, were identified by the women.

National data system on near miss and maternal death: shifting from maternal risk to public health impact in Nigeria

Background

The lack of reliable and up-to-date statistics on maternal deaths and disabilities remains a major challenge to the implementation of Nigeria's Road Map to Accelerate the Millennium Development Goal related to Maternal Health (MDG-5). There are currently no functioning national data sources on maternal deaths and disabilities that could serve as reference points for programme managers, health advocates and policy makers. While awaiting the success of efforts targeted at overcoming the barriers facing establishment of population-based data systems, referral institutions in Nigeria can contribute their quota in the quest towards MDG-5 by providing good quality and reliable information on maternal deaths and disabilities on a continuous basis. This project represents the first opportunity to initiate a scientifically sound and reliable quantitative system of data gathering on maternal health profile in Nigeria.

Objective

The primary objective is to create a national data system on maternal near miss (MNM) and maternal mortality in Nigerian public tertiary institutions. This system will conduct periodically, both regionally and at country level, a review of the magnitude of MNM and maternal deaths, nature of events responsible for MNM and maternal deaths, indices for the quality of care for direct obstetric complications and the health service events surrounding these complications, in an attempt to collectively define and monitor the standard of comprehensive emergency obstetric care in the country.

Methods

This will be a nationwide cohort study of all women who experience MNM and those who die from pregnancy, childbirth and puerperal complications using uniform criteria among women admitted in tertiary healthcare facilities in the six geopolitical zones in Nigeria. This will be accomplished by establishing a network of all public tertiary obstetric referral institutions that will prospectively collect specific information on potentially fatal maternal complications. For every woman enrolled, the health service events (care pathways) within the facility will be evaluated to identify areas of substandard care/avoidable factors through clinical audit by the local research team. A summary estimate of the frequencies of MNM and maternal deaths will be determined at intervals and indicators of quality of care (case fatality rate, both total and cause-specific and mortality index) will be evaluated at facility, regional and country levels.

Management

Overall project management will be from the Centre for Research in Reproductive Health (CRRH), Sagamu, Nigeria. There will be at least two meetings and site visits for efficient coordination of the project by regional coordinators and central coordinating staff. Data will be transferred electronically by hospital and regional coordinators and managed at the Data Management Unit of CRRH, Sagamu, Nigeria.

Expected outcomes

The outcome of the study would provide useful information to the health practitioners, policy-makers and international partners on the strengths and weaknesses of the infrastructures provided for comprehensive emergency obstetric care in Nigeria. The successful implementation of this project will pave way for the long-awaited Confidential Enquiries into Maternal Deaths that would guide the formulation and or revision of obstetric policies and practices in Nigeria. Lessons learnt from the establishment of this data system can also be used to set up similar structures at lower levels of healthcare delivery in Nigeria.