Achieving Surgical, Obstetric, Trauma, and Anesthesia (SOTA) care for all in South Asia

South Asia is a demographically crucial, economically aspiring, and socio-culturally diverse region in the world. The region contributes to a large burden of surgically-treatable disease conditions. A large number of people in South Asia cannot access safe and affordable surgical, obstetric, trauma, and anesthesia (SOTA) care when in need. Yet, attention to the region in Global Surgery and Global Health is limited. Here, we assess the status of SOTA care in South Asia. We summarize the evidence on SOTA care indicators and planning. Region-wide, as well as country-specific challenges are highlighted. We also discuss potential directions-initiatives and innovations-toward addressing these challenges. Local partnerships, sustained research and advocacy efforts, and politics can be aligned with evidence-based policymaking and health planning to achieve equitable SOTA care access in the South Asian region under the South Asian Association for Regional Cooperation (SAARC).

Estimating access to surgical care: A community centered national household survey from Pakistan

Pakistan is a lower middle-income country in South Asia with a population of 225 million. No estimate for surgical care access exists for the country. We postulate the estimated access to surgical care is less than the minimum 80% to be achieved by 2030. We conducted a randomized, stratified two-stage cluster household survey. A sample of 770 households was selected using 2017 census frames from the Pakistan Bureau of Statistics. Data was collected on choice of hospital and travel time to the chosen hospital for C-section, laparotomy, open fracture repair (OFR), and specialized surgery. Analysis was conducted using Stata 14. Access to all Bellwether surgeries (C-section, laparotomy, and open fracture repair) in Pakistan is estimated to be 74.8%. However, estimated access in rural areas and the provinces of Balochistan, Khyber Pakhtunkhwa (KP) and Sindh is far less than in urban areas and in Punjab and Islamabad. Estimated access to C-sections is more compared to OFR, laparotomy, and specialized surgery. Health system strengthening efforts should focus on improving surgical care access in rural areas and in Balochistan, KP, and Sindh. More focus is required on standardizing the availability and quality of surgical services in secondary-level hospitals.

Hospital care for critical illness in low-resource settings: lessons learned during the COVID-19 pandemic

Care for the critically ill patients is often considered synonymous with a hospital having an intensive care unit. However, a focus on Essential Emergency and Critical Care (EECC) may obviate the need for much intensive care. Severe COVID-19 presented a specific critical care challenge while also being an exemplar of critical illness in general. Our multidisciplinary team conducted research in Kenya and Tanzania on hospitals' ability to provide EECC as the COVID-19 pandemic unfolded. Important basic inputs were often lacking, especially sufficient numbers of skilled health workers. However, we learnt that higher scores on resource readiness scales were often misleading, as resources were often insufficient or not functional in all the clinical areas they are needed. By following patient journeys, through interviews and group discussions, we revealed gaps in timeliness, continuity and delivery of care. Generic challenges in transitions between departments were identified in the receipt of critically ill patients, the ability to sustain monitoring and treatment and preparation for any subsequent transition. While the global response to COVID-19 focused initially on providing technologies and training, first ventilators and later oxygen, organisational and procedural challenges seemed largely ignored. Yet, they may even be exacerbated by new technologies. Efforts to improve care for the critically ill patients, which is a complex process, must include a whole system and whole facility view spanning all areas of patients' care and their transitions and not be focused on a single location providing 'critical care'. We propose a five-part strategy to support the system changes needed.

A geospatial database of close-to-reality travel times to obstetric emergency care in 15 Nigerian conurbations

Travel time estimation accounting for on-the-ground realities between the location where a need for emergency obstetric care (EmOC) arises and the health facility capable of providing EmOC is essential for improving pregnancy outcomes. Current understanding of travel time to care is inadequate in many urban areas of Africa, where short distances obscure long travel times and travel times can vary by time of day and road conditions. Here, we describe a database of travel times to comprehensive EmOC facilities in the 15 most populated extended urban areas of Nigeria. The travel times from cells of approximately 0.6 × 0.6 km to facilities were derived from Google Maps Platform's internal Directions Application Programming Interface, which incorporates traffic considerations to provide closer-to-reality travel time estimates. Computations were done to the first, second and third nearest public or private facilities. Travel time for eight traffic scenarios (including peak and non-peak periods) and number of facilities within specific time thresholds were estimated. The database offers a plethora of opportunities for research and planning towards improving EmOC accessibility.

Preeclampsia and eclampsia-specific maternal mortality in Bangladesh: Levels, trends, timing, and care-seeking practices

Background

Despite improvements in many health indicators, maternal mortality has plateaued in Bangladesh. Achieving the global target of reductions in maternal mortality and the associated Sustainable Development Goals will not be possible without actions to prevent deaths due to preeclampsia/eclampsia. Here we examined the levels, trends, specific causes, timing, place, and care-seeking behaviours of women who died due to these two causes.

Methods

We used nationally representative Bangladesh Maternal Mortality and Health Care Surveys (BMMSs) conducted in 2001, 2010, and 2016 to examine levels and trends of deaths due to preeclampsia/eclampsia. We based the analysis of specific causes, timing, and place of preeclampsia/eclampsia deaths, and care seeking before the deaths on 41 such deaths captured in the 2016 survey. We also used BMMS 2016 survey verbal autopsy (VA) questionnaire to highlight stories that put faces to the numbers.

Results

The preeclampsia/eclampsia-specific mortality ratio decreased from 77 per 100 000 live births in the 2001 BMMS to 40 per 100 000 live births in the 2010 BMMS, yet halted in the 2016 BMMS at 46 per 100 000 live births. Although preeclampsia/eclampsia accounted for around one-fifth of all maternal deaths in the 2010 BMMS, in the 2016 BMMS, the percentage contribution reached the 2001 BMMS level of 24%. An analysis of the VA questionnaire's open section showed that almost all such death cases left their homes to seek care; however, most had to visit more than one facility before they died, indicating an unprepared health system.

Conclusions

A cluster of preeclampsia/eclampsia-specific mortality observed during the first trimester, during delivery, and within 48 hours of birth indicates a need for preconception health check-ups and strengthened facility readiness. Awareness of maternal complications, proper care seeking, and healthy reproductive practices, like family planning to space and limit pregnancy through client-supportive counselling, may be beneficial. Improving regular and emergency maternal services readiness is also essential.

The impact of the Safe Delivery Application on knowledge and skills managing postpartum haemorrhage in a low resource setting: a cluster randomized controlled trial in West Wollega region, Ethiopia

BACKGROUND

Postpartum haemorrhage is one of the leading causes of maternal mortality in low-income countries. Improving health workers' competencies in obstetric emergencies in low-income settings, has been recognized as an important factor in preventing maternal mortality and morbidity. mHealth interventions in maternal and newborn health care has shown the potential to improve health service delivery. Strong study designs such as randomized controlled trials are missing to estimate the effectiveness of the mHealth interventions.

METHODS

Between August 2013 and August 2014, 70 health facilities in West Wollega Region, Ethiopia were included and randomized to intervention or control in a cluster randomized controlled trial. At intervention facilities birth attendants were provided with a smartphone with the SDA installed. Of 176 midwives and "health extension workers," 130 completed at 12 months follow-up. At baseline and after 6- and 12-months participants were assessed. Knowledge was tested by a Key Feature Questionnaire, skills by an Objective Structured Assessment of Technical Skills in a structured role-play scenario.

RESULTS

Baseline skills scores were low and comparable with a median of 12/100 in the intervention and the control group. After 6 months skills had doubled in the intervention group (adjusted mean difference 29.6; 95% CI 24.2-35.1 compared to 1·8; 95% CI - 2.7 to 6.3 in the control group). At 12 months skills had further improved in the intervention group (adjusted mean difference 13.3; 95% CI 8.3-18.3 compared to 3.1; 95% CI - 1.0 to 7.3 in the control group). Knowledge scores also significantly improved in the intervention group compared to the control (adjusted mean difference after 12 months 8.5; 95% CI 2.0-15.0).

CONCLUSION

The Safe Delivery App more than doubled clinical skills for managing postpartum haemorrhage among birth attendants making it an attractive tool to reduce maternal mortality.

TRIAL REGISTRATION

Clinicaltrial.gov Identifier NCT01945931. September 5, 2013.

Maternal pre-pregnancy BMI, MTHFR polymorphisms, and the risk of adverse pregnancy outcomes in pregnant women from South China: a retrospective cohort study

BACKGROUND

Increasing evidence suggests an association between maternal pre-pregnancy body mass index (pre-BMI) and adverse pregnancy outcomes. However, the effects of methylenetetrahydrofolate reductase (MTHFR) polymorphisms on these relationships require further investigation. This study aimed to investigate whether the relationship between pre-BMI and the risk of adverse pregnancy outcomes was influenced by MTHFR gene polymorphisms.

METHODS

A total of 5614 mother-fetus pairs were included in the study. The odds ratios (OR) of adverse pregnancy complications, including gestational diabetes mellitus (GDM), gestational hypertension (GHT), cesarean delivery (CS), and premature rupture of membranes (PROM), were estimated using adjusted logistic regression models and subgroup analysis.

RESULTS

Pregnant women with higher pre-BMI values were positively related to the risk of GDM, GHT, and CS. In the subgroup analysis, underweight BMI was associated with a decreased risk of CS and GDM in pregnant women with the MTHFR A1298C AA or C677T CC genotype, while overweight/obese BMI was associated with an increased risk of GDM and CS in different MTHFR variants. Moreover, pregnant women with MTHFR A1298C AC + CC or C667T CC were found to have an increased risk of GHT in the MTHFR A1298C AA or C667T CT + TT genotype. A remarkable association was observed between the obesity group with MTHFR A1298C AC + CC (OR = 6.49, CI: 2.67-15.79) and the overweight group with the C667T CC genotype (OR = 4.72, CI: 2.13-10.45).

CONCLUSIONS

MTHFR gene polymorphisms exert a modifying effect on the association between maternal pre-BMI and the risk of GHT, CS, and GDM. Pregnant women with a high pre-BMI with specific MTHFR genotypes should be considered for GHT development.

Improving comprehensive emergency obstetric and newborn care in Tanzania: A qualitative study

AIM

The purpose of this qualitative study was to explore how health care professionals, managers and community members experienced the implementation of a training program in comprehensive emergency obstetric and neonatal care training in rural Tanzania.

BACKGROUND

Given the high rates of maternal and newborn mortality in Tanzania, the government committed to improving maternal health by increasing access to health care; improving reproductive, maternal, newborn health; reducing maternal and neonate mortality; and increasing the number of public health centers with emergency obstetric and neonatal care. To address the gap in emergency obstetric and neonatal care amongst the health workforce, five health care facilities in rural Tanzania participated in a 3-month specialized training program. The training was geared to increase access to skilled deliveries, prevent maternal and neonate deaths, and reduce referrals to district hospitals.

METHODS

Twenty-four focus group discussions were held with members of Council Health Management Team, Health Facility Management Team, staff who received training, and community members. Data collection and analysis was guided by content analysis and the World Health Organization's availability, accessibility, acceptability, and quality framework.

FINDINGS

Participants reported acquiring necessary skills that enabled them to provide quality and safe obstetric and newborn care. Five themes emerged from the analysis 1) competent and confident health care teams, 2) renewed commitment to teamwork, 3) community confidence and trust in the health team, 4) mentorship as a critical element of success, and 5) enhancing training and practice. These five emerging themes demonstrate enhanced confidence and trust by the community and increased competency of health care teams to support mothers through pregnancy and birth at the health centre.

CONCLUSION

The competencies acquired by health care providers demonstrate an increase in staff commitment and teamwork. There is an increased number of deliveries in health centres, a declining trend of maternal and neonate deaths and referrals to other health centres because the health care providers are capable of competently and confidently providing emergency obstetric and neonatal care services.

Association between high levels of comorbid anxiety and depressive symptoms and decreased likelihood of birth without intervention: A longitudinal prospective cohort study

OBJECTIVE

To assess the association between trajectories of comorbid anxiety and depressive (CAD) symptoms assessed in each pregnancy trimester and physiological birth.

DESIGN

Large longitudinal prospective cohort study with recruitment between January 2013 and September 2014.

SETTING

Primary care, in the Netherlands.

POPULATION

Dutch-speaking pregnant women with gestational age at birth ≥37 weeks, and without multiple pregnancy, severe psychiatric disorder or chronic disease history.

METHODS

Pregnancy-specific anxiety and depressive symptoms were measured prospectively in each trimester of pregnancy using the negative affect subscale of the Tilburg Pregnancy Distress Scale and Edinburgh (Postnatal) Depression Scale. Data on physiological birth were obtained from obstetric records. Multivariate growth mixture modelling was performed in MPLUS to determine longitudinal trajectories of CAD symptoms. Multiple logistic regression analysis was used to examine the association between trajectories and physiological birth.

MAIN OUTCOME MEASURES

Trajectories of CAD symptoms and physiological birth.

RESULTS

Seven trajectories (classes) of CAD symptoms were identified in 1682 women and subsequently merged into three groups: group 1-persistently low levels of symptoms (reference class 1; 79.0%), group 2-intermittently high levels of symptoms (classes 3, 6 and 7; 11.2%), and group 3-persistently high levels of symptoms (classes 2, 4 and 5; 9.8%). Persistently high levels of CAD symptoms (group 3) were associated with a lower likelihood of physiological birth (odds ratio 0.67, 95% confidence interval 0.47-0.95, P = 0.027) compared with the reference group (persistently low levels of symptoms), after adjusting for confounders.

CONCLUSIONS

This study is the first showing evidence that persistently high CAD levels, assessed in each pregnancy trimester, are associated with a lower likelihood of physiological birth.

Effective Coverage of Emergency Obstetric and Newborn Care Services in Africa: A Scoping Review

Objective

This scoping review aimed to map the evidence of effective coverage (EC) of EmONC (Emergency Obstetric and Neonatal Care) services and associated factors in Africa.

Methodology

The review used PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews) checklist to select, appraise, and report the findings. We searched four databases (PubMed, Web of Science, Google Scholar, and Scopus) and grey literature published between Jan 01, 2011 - Dec 31, 2020. The search terms included "emergency", "obstetric", "newborn", "effective coverage", and "quality" with Boolean terms, AND and OR. The review was conducted using title, abstract, and full-article screenings. The results were analyzed thematically using NVivo v12 qualitative research data analysis software.

Results

Of the 1811 searched studies, 32 met the eligibility criteria for review. The majority of the studies were from East (56.3%) and Western (28.1%) Africa. Most studies were cross-sectional, had targeted health facilities, and combined two or more data collection techniques. The thematic analysis yielded three themes: EmONC service utilization, quality of EmONC service, and factors associated with the quality of EmONC services. The review showed a scarcity of evidence and variations regarding the crude coverage, quality of care, and factors affecting the quality of EmONC services in Africa.

Conclusion

The review reported that the utilization of EmONC services was below the WHO-recommended 100% in all studies, though some reported improvements over time. Disparities in EmONC services quality were paramount across studies and contexts. However, the methodological and analytical incongruity across studies brought difficulties in tracing and comparing the progress made in EmONC services utilizations.

Registration

This scoping review protocol was first registered on the Open Science Framework (OSF) on Aug 27, 2021 (https://osf.io/khcte/).

Barriers and enablers to emergency obstetric and newborn care services use in Wolaita Zone, Southern Ethiopia: a qualitative case study

BACKGROUND

Globally, 11.4 million untreated obstetric complications did not receive Emergency Obstetric and Newborn Care (EmONC) services yearly, with the highest burden in low and middle-income countries. Half of the Ethiopian women with obstetric complications did not receive EmONC services. However, essential aspects of the problem have not been assessed in depth. This study, therefore, explored the various aspects of barriers and enablers to women's EmONC services utilization in southern Ethiopia.

METHODOLOGY

A qualitative case study research design was used in nine districts of the Wolaita Zone. A total of 37 study participants were selected using a purposive stratified sampling technique and interviewed till data saturation. Twenty-two key informant interviews were conducted among front-line EmONC service providers, managers, community leaders, and traditional birth attendants (TBAs). Individual in-depth interviews were conducted among 15 women with obstetric complications. The trustworthiness of the research was assured by establishing credibility, transferability, conformability, and dependability. NVivo 12 was used to assist with the thematic data analysis.

RESULT

Five themes emerged from the analysis: service users' perception and experience (knowledge, perceived quality, reputation, respectful care, and gender); community-related factors (misconceptions, traditional practices, family and peer influence, and traditional birth attendants' role); access and availability of services (infrastructure and transportation); healthcare financing (drugs and supplies, out-of-pocket expenses, and fee exemption); and health facility-related factors (competency, referral system, waiting time, and leadership).

CONCLUSION

Many women and their newborns in the study area suffered severe and life-threatening complications because of the non-utilization or delayed utilization of EmONC services. A key policy priority should be given to enhancing women's awareness, eliminating misconceptions, improving women's autonomy, and ensuring traditional practices' role in EmONC service utilization. Community awareness interventions are required to enhance service uptake. Furthermore, the health systems must emphasize improving the quality of care, inequitable distribution of EmONC facilities, and essential drugs. The financial constraints need to be addressed to motivate women from low socioeconomic status. Furthermore, intersectoral collaboration is required to maintain a legal framework to control and prohibit home deliveries and empower women.

Improving access to emergency obstetric care in underserved rural Tanzania: a prospective cohort study

Background

One of the key strategies to reducing maternal mortality is provision of emergency obstetric care services. This paper describes the results of improving availability of, and access to emergency obstetric care services in underserved rural Tanzania using associate clinicians.

Methods

A prospective cohort study of emergency obstetric care was implemented in seven health centres in Morogoro region, Tanzania from July 2016 to June 2019. In early 2016, forty-two associate clinicians from five health centres were trained in teams for three months in emergency obstetric care, newborn care and anaesthesia. Two health centres were unexposed to the intervention and served as controls. Following training, virtual teleconsultation, quarterly on-site supportive supervision and continuous mentorship were implemented to reinforce skills and knowledge.

Results

The met need for emergency obstetric care increased significantly from 45% (459/1025) at baseline (July 2014 – June 2016) to 119% (2010/1691) during the intervention period (Jul 2016 – June 2019). The met need for emergency obstetric care in the control group also increased from 53% (95% CI 49–58%) to 77% (95% CI 74–80%). Forty maternal deaths occurred during the baseline and intervention periods in the control and intervention health centres. The direct obstetric case fatality rate decreased slightly from 1.5% (95% CI 0.6–3.1%) to 1.1% (95% CI 0.7–1.6%) in the intervention group and from 3.3% (95% CI 1.2–7.0%) to 0.8% (95% CI 0.2–1.7%) in the control group.

Conclusions

When emergency obstetric care services are made available the proportion of obstetric complications treated in the facilities increases. However, the effort to scale up emergency obstetric care services in underserved rural areas should be accompanied by strategies to reinforce skills and the referral system.

A Comprehensive Approach to Improving Emergency Obstetric and Newborn Care in Kigoma, Tanzania

Efforts to increase the availability and utilization of high-quality emergency obstetric and newborn care and routine delivery care services in Kigoma were successful and subsequently contributed to significant reductions in maternal and perinatal mortality in the region.

Introduction:

To address high levels of maternal mortality in Kigoma, Tanzania, stakeholders increased women's access to high-quality comprehensive emergency obstetric and newborn care (EmONC) by decentralizing services from hospitals to health centers where EmONC was delivered mostly by associate clinicians and nurses. To ensure that women used services, implementers worked to continuously improve and sustain quality of care while creating demand.

Methods:

Program evaluation included periodic health facility assessments, pregnancy outcome monitoring, and enhanced maternal mortality detection region-wide in program- and nonprogram-supported health facilities.

Results:

Between 2013 and 2018, the average number of lifesaving interventions performed per facility increased from 2.8 to 4.7. The increase was higher in program-supported than nonprogram-supported health centers and dispensaries. The institutional delivery rate increased from 49% to 85%; the greatest increase occurred through using health centers (15% to 25%) and dispensaries (21% to 46%). The number of cesarean deliveries almost doubled, and the population cesarean delivery rate increased from 2.6% to 4.5%. Met need for emergency obstetric care increased from 44% to 61% while the direct obstetric case fatality rate declined from 1.8% to 1.4%. The institutional maternal mortality ratio across all health facilities declined from 303 to 174 deaths per 100,000 live births. The total stillbirth rate declined from 26.7 to 12.8 per 1,000 births. The predischarge neonatal mortality rate declined from 10.7 to 7.6 per 1,000 live births. Changes in case fatality rate and maternal mortality were driven by project-supported facilities. Changes in neonatal mortality varied depending on facility type and program support status.

Conclusion:

Decentralizing high-quality comprehensive EmONC delivered mostly by associate clinicians and nurses led to significant improvements in the availability and utilization of lifesaving care at birth in Kigoma. Dedicated efforts to sustain high-quality EmONC along with supplemental programmatic components contributed to the reduction of maternal and perinatal mortality.

Improving Emergency Care Through a Dedicated Redesigned Obstetrics and Gynecology Emergency Unit at the Women's Hospital, Doha, Qatar

BACKGROUND

OBJECTIVE

STUDY DESIGN

RESULTS

CONCLUSION

The status of emergency obstetric and newborn care in post-conflict eastern DRC: a facility-level cross-sectional study

Background

Pregnancy-related mortality remains persistently higher in post-conflict areas. Part of the blame lies with continued disruption to vital care provision, especially emergency obstetric and newborn care (EmONC). In such settings, assessment of EmONC is essential for data-driven interventions needed to reduce preventable maternal and neonatal mortality. In the North Kivu Province (NKP), the epicentre of armed conflict in eastern Democratic Republic of the Congo (DRC) between 2006 and 2013, the post-conflict status of EmONC is unknown. We assessed the availability, use, and quality of EmONC in 3 health zones (HZs) of the NKP to contribute to informed policy and programming in improving maternal and newborn health (MNH) in the region.

Method

A cross-sectional survey of all 42 public facilities designated to provide EmONC in 3 purposively selected HZs in the NKP (Goma, Karisimbi, and Rutshuru) was conducted in 2017. Interviews, reviews of maternity ward records, and observations were used to assess the accessibility, use, and quality of EmONC against WHO standards.

Results

Only three referral facilities (two faith-based facilities in Goma and the MSF-supported referral hospital of Rutshuru) met the criteria for comprehensive EmONC. None of the health centres qualified as basic EmONC, nor could they offer EmONC services 24 h, 7 days a week (24/7). The number of functioning EmONC per 500,000 population was 1.5. Assisted vaginal delivery was the least performed signal function, followed by parenteral administration of anticonvulsants, mainly due to policy restrictions and lack of demand. The 3 HZs fell short of WHO standards for the use and quality of EmONC. The met need for EmONC was very low and the direct obstetric case fatality rate exceeded the maximum acceptable level. However, the proportion the proportion of births by caesarean section in EmONC facilities was within acceptable range in the HZs of Goma and Rutshuru. Overall, the intrapartum and very early neonatal death rate was 1.5%.

Conclusion

This study provides grounds for the development of coordinated and evidence-based programming, involving local and external stakeholders, as part of the post-conflict effort to address maternal and neonatal morbidity and mortality in the NKP. Particular attention to basic EmONC is required, focusing on strengthening human resources, equipment, supply chains, and referral capacity, on the one hand, and on tackling residual insecurity that might hinder 24/7 staff availability, on the other.

Prehospital emergency obstetric and neonatal care train-the-trainers program in Rwanda

OBJECTIVE

To improve maternal mortality rates, our collaboration developed and implemented a context-specific, prehospital Emergency Obstetrics and Neonatal Course (EONC) and train-the-trainers program in Rwanda.

METHODS

Two cohorts of staff participated in the program-the SAMU emergency medical service and staff from district hospitals. A 2-day course was developed, consisting of skills stations, simulations, and didactics. A 50-question assessment was administered to both cohorts before and after the courses. Student's t test and matched paired t tests were used to evaluate the assessments through retrospective analysis of the data.

RESULTS

EONC1 median scores were 60% versus 92% (pre vs post), using matched-pair analysis of 20 participants. EONC2 median scores were 52% versus 96% (pre vs post), using matched-pair analysis of participants. A one-way analysis of variance mean square analysis showed that regardless of the baseline level of training for each participant, all trainees reached similar post-course assessment scores (F(1)  = 8.35, P = 0.0059).

CONCLUSION

Optimal prehospital management of obstetric emergencies is essential to prevent needless mortality and morbidity. This study demonstrated that a context-appropriate prehospital obstetric and neonatal training program could be effectively developed and implemented for the SAMU team in Kigali, Rwanda.

Why women die after reaching the hospital: a qualitative critical incident analysis of the 'third delay' in postconflict northern Uganda

OBJECTIVES

To critically explore and describe the pathways that women who require emergency obstetrics and newborn care (EmONC) go through and to understand the delays in accessing EmONC after reaching a health facility in a conflict-affected setting.

DESIGN

This was a qualitative study with two units of analysis: (1) critical incident technique (CIT) and (2) key informant interviews with health workers, patients and attendants.

SETTING

Thirteen primary healthcare centres, one general private-not-for-profit hospital, one regional referral hospital and one teaching hospital in northern Uganda.

PARTICIPANTS

Forty-nine purposively selected health workers, patients and attendants participated in key informant interviews. CIT mapped the pathways for maternal deaths and near-misses selected based on critical case purposive sampling.

RESULTS

After reaching the health facility, a pregnant woman goes through a complex pathway that leads to delays in receiving EmONC. Five reasons were identified for these delays: shortage of medicines and supplies, lack of blood and functionality of operating theatres, gaps in staff coverage, gaps in staff skills, and delays in the interfacility referral system. Shortage of medicines and supplies was central in most of the pathways, characterised by three patterns: delay to treat, back-and-forth movements to buy medicines or supplies, and multiple referrals across facilities. Some women also bypassed facilities they deemed to be non-functional.

CONCLUSION

Our findings show that the pathway to EmONC is precarious and takes too long even after making early contact with the health facility. Improvement of skills, better management of the meagre human resource and availing essential medical supplies in health facilities may help to reduce the gaps in a facility's emergency readiness and thus improve maternal and neonatal outcomes.

Availability, utilization and quality of emergency obstetric care services in Sousse, Tunisia

Introduction

emergency obstetric care (EmOC) is a high-impact priority intervention strongly recommended for improving maternal health outcomes. The objectives of this study were to assess the availability, utilization, and quality of emergency obstetric care services in the Governorate of Sousse (Tunisia).

Methods

a cross-sectional study was conducted among public health facilities which performed deliveries in Sousse in 2017. Data were collected by consulting clinical records and registers and interviewing staff using WHO EmOC tools. Emergency obstetric care (EmOC) indicators were calculated.

Results

only the University maternity Unit functioned as full comprehensive EmOC facility. No other public facility provided all the 7 Basic EmOC signal functions 3 months prior to the survey. The unperformed signal functions were: administration of parenteral antibiotics, manual removal of placenta and assisted vaginal delivery. The number of EmOC facilities was 0.72 per 500,000 inhabitants. The met need for EmOC was 89.5%. The proportion of caesarean section was 24.2%. The direct obstetric case fatality rate was 0.159% and intrapartum and very early neonatal death rate was 0.65%.

Conclusion

raising maternity facilities to a minimum level of basic EmOC status would be a major contributing step towards maternal mortality reduction.

Development and launch of the first obstetrics and gynaecology master of medicine residency training programme in Botswana

BACKGROUND

Sub-Saharan Africa (SSA) faces a severe shortage of Obstetrician Gynaecologists (OBGYNs). While the Lancet Commission for Global Surgery recommends 20 OBGYNs per 100,000 population, Botswana has only 40 OBGYNs for a population of 2.3 million. We describe the development of the first OBGYN Master of Medicine (MMed) training programme in Botswana to address this human resource shortage.

METHODS

We developed a 4-year OBGYN MMed programme at the University of Botswana (UB) using the Kern's approach. In-line with UB MMed standards, the programme includes clinical apprenticeship training complemented by didactic and research requirements. We benchmarked curriculum content, learning outcomes, competencies, assessment strategies and research requirements with regional and international programmes. We engaged relevant local stakeholders and developed international collaborations to support in-country subspecialty training.

RESULTS

The OBGYN MMed curriculum was completed and approved by all relevant UB bodies within ten months during which time additional staff were recruited and programme financing was assured. The programme was advertised immediately; 26 candidates applied for four positions, and all selected candidates accepted. The programme was launched in January 2020 with government salary support of all residents. The clinical rotations and curricular development have been rolled out successfully. The first round of continuous assessment of residents was performed and internal programme evaluation was conducted. The national accreditation process was initiated.

CONCLUSION

Training OBGYNs in-country has many benefits to health systems in SSA. Curricula can be adjusted to local resource context yet achieve international standards through thoughtful design and purposeful collaborations.

Emergency and essential surgical healthcare services during COVID-19 in low- and middle-income countries: A perspective

The COVID-19 pandemic resulted in significant changes in health care systems worldwide, with low- and middle-income countries (LMIC) sustaining important repercussions. Specifically, alongside cancellation and postponements of non-essential surgical services, emergency and essential surgical care delivery may become affected due to the shift of human and material resources towards fighting the pandemic. For surgeries that do get carried through, new difficulties arise in protecting surgical personnel from contracting SARS-CoV-2. This scarcity in LMIC surgical ecosystems may result in higher morbidity and mortality, in addition to the COVID-19 toll. This paper aims to explore the potential consequences of COVID-19 on the emergency and essential surgical care in LMICs, to offer recommendations to mitigate damages and to reflect on preparedness for future crises. Reducing the devastating consequences of the COVID-19 pandemic on LMIC emergency and essential surgical services can be achieved through empowering communities with accurate information and knowledge on prevention, optimizing surgical material resources, providing quality training of health care personnel to treat SARS-CoV-2, and ensuring adequate personal protection equipment for workers on the frontline. While LMIC health systems are under larger strain, the experience from previous outbreaks may aid in order to innovate and adapt to the current pandemic. Protecting LMIC surgical ecosystems will be a pivotal process in ensuring that previous health system strengthening efforts are preserved, comprehensive care for populations worldwide are ensured, and to allow for future developments beyond the pandemic.

Perinatal outcomes of cesarean deliveries in Sierra Leone: A prospective multicenter observational study

OBJECTIVE

To analyze the indications for cesarean deliveries and factors associated with adverse perinatal outcomes in Sierra Leone.

METHODS

Between October 2016 and May 2017, patients undergoing cesarean delivery performed by medical doctors and associate clinicians in nine hospitals were included in a prospective observational study. Data were collected perioperatively, at discharge, and during home visits after 30 days.

RESULTS

In total, 1274 cesarean deliveries were included of which 1099 (86.3%) were performed as emergency surgery. Of the 1376 babies, 261 (19.0%) were perinatal deaths (53 antepartum stillbirths, 155 intrapartum stillbirths, and 53 early neonatal deaths). Indications with the highest perinatal mortality were uterine rupture (45 of 55 [81.8%]), abruptio placentae (61 of 85 [71.8%]), and antepartum hemorrhage (8 of 15 [53.3%]). In the group with cesarean deliveries performed for obstructed and prolonged labor, a partograph was filled out for 212 of 425 (49.9%). However, when completed, babies had 1.81-fold reduced odds for perinatal death (95% confidence interval 1.03-3.18, P-value 0.041).

CONCLUSION

Cesarean deliveries in Sierra Leone are associated with an exceptionally high perinatal mortality rate of 190 per 1000 births. Late presentation in the facilities and lack of adequate fetal monitoring may be contributing factors.

Giving birth in Ethiopia: a spatial and multilevel analysis to determine availability and factors associated with healthcare facility births

OBJECTIVE

To assess spatial variations in the use of healthcare facilities for birth and to identify associated factors.

DESIGN

Cross-sectional analysis of population- and healthcare facility-based data.

SETTING

Ethiopia Demographic and Health Survey (EDHS 2016) linked to Service Provision Assessment data (SPA 2014).

POPULATION

A sample of 6954 women who gave birth in the 5 years preceding EDHS 2016 and 717 healthcare facilities providing delivery care.

METHODS

Secondary data analysis of linked population and health facility data was conducted. Multilevel and spatial analyses were conducted to identify key determinants of women's use of health facilities for birth and to assess spatial clustering of facility births.

MAIN OUTCOME MEASURE

Health facility birth.

RESULTS

A one-unit increase in the mean score of the readiness of health facilities to provide basic emergency obstetric care (EmOC) was associated with a two-fold increase in the odds of facility birthing (adjusted odds ratio, aOR, 2.094, 95% CI 1.187-3.694). A woman's attendance for at least four antenatal care visits was significantly associated with facility birth (aOR 8.863, 95% CI 6.748-11.640). Distance to a healthcare facility was inversely related to a woman's use of facility birthing (aOR 0.967, 95% CI 0.944-0.991). Women in the richest wealth quintile were also more likely to have facility births (aOR 2.892, 95% CI 2.199-3.803).

CONCLUSIONS

There were geographic variations in facility births in Ethiopia, revealing critical gaps in service availability and readiness. It is important to ensure that health facilities are in a state of readiness to provide EmOC.

TWEETABLE ABSTRACT

Failure to ensure health facility readiness is associated with failure to give birth at a healthcare facility.

Assessing capacity of health facilities to provide routine maternal and newborn care in low-income settings: what proportions are ready to provide good-quality care, and what proportions of women receive it?

Background

Good quality maternal and newborn care at primary health facilities is essential, but in settings with high maternal and newborn mortality the evidence for the protective effect of facility delivery is inconsistent. We surveyed samples of health facilities in three settings with high maternal mortality to assess their readiness to provide routine maternal and newborn care, and proportions of women using facilities that were ready to offer good quality care. Surveys were conducted in 2012 and 2015 to assess changes over time.

Methods

Surveys were conducted in Ethiopia, the Indian state of Uttar Pradesh and Gombe State in North-Eastern Nigeria. At each facility the staffing, infrastructure and commodities were quantified. These formed components of four “signal functions” that described aspects of routine maternal and newborn care. A facility was considered ready to perform a signal function if all the required components were present. Readiness to perform all four signal functions classed a facility as ready to provide good quality routine care. From facility registers we counted deliveries and calculated the proportions of women delivering in facilities ready to offer good quality routine care.

Results

In Ethiopia the proportion of deliveries in facilities classed as ready to offer good quality routine care rose from 40% (95% confidence interval (CI) 26–57) in 2012 to 43% (95% CI 31–56) in 2015. In Uttar Pradesh these estimates were 4% (95% CI 1–24) in 2012 and 39% (95% CI 25–55) in 2015, while in Nigeria they were 25% (95% CI 6–66) in 2012 and zero in 2015. Improved facility readiness in Ethiopia and Uttar Pradesh arose from increased supplies of commodities, while in Nigeria facility readiness fell due to depleted commodity supplies and fewer Skilled Birth Attendants.

Conclusions

This study quantified the readiness of health facilities to offer good quality routine maternal and newborn care, and may help explain inconsistent outcomes of facility care in some settings. Signal function methodology can provide a rapid and inexpensive measure of such facility readiness. Incorporating data on facility deliveries and repeating the analyses highlighted adjustments that could have greatest impact upon routine maternal and newborn care.

Quality assessment of abortion care from the users' perspective: dimensional structure of the QualiAborto-Pt questionnaire

Abortion complications are a major public health problem, and studies to assess the quality of abortion care require adequate measurement tools. This study is a continuation of such an instrument's refinement, the QualiAborto-Pt questionnaire. Using data from a survey of 2,336 women hospitalized for abortion complications in 19 hospitals in three state capitals in Northeast Brazil (Salvador - Bahia, Recife - Pernambuco, and São Luís - Maranhão), we implemented a series of exploratory and confirmatory factor analyses based on a 55-item prototype. The analyses indicate a structure with 17 items in five dimensions: reception, orientation, inputs/physical environment, technical quality, and continuity of care. All the items in the final model displayed acceptable reliability, absence of content redundancy, and factor specificity, as well as theoretical consistency with the respective dimensions. The solution also shows discriminant factor validity. Despite some persistent issues for further analysis and clarification, this version merits recommendation for use in Brazil.

Promoting Health Equity Through Purposeful Design and Professionalization of Resident Global Health Electives in Obstetrics and Gynecology

OBJECTIVE

To design an Obstetrics and Gynecology (OBGYN) residency elective in global health that meets ACGME standards and simultaneously promotes health equity.

DESIGN

A 4-week elective was established for US residents in a high-volume African district hospital that served as a site for OBGYN rotations for the national internship training program. Clear clinical, operative, and teaching requirements were delineated for US OBGYN residents. Resident formal didactic outputs were incorporated into the intern OBGYN curriculum. The program was evaluated through assessment of resident experience and contribution to local training, as well as assessment of intern competency in OBGYN.

SETTING

Scottish Livingstone Hospital, a public district hospital in Molepolole, Botswana.

PARTICIPANTS

Second- to fourth-year OBGYN residents from US training programs, working with Batswana medical interns under on-site faculty supervision.

RESULTS

From May 2016 to June 2018, 18 residents from 9 US OBGYN residency programs participated in the elective. Under supervision, US residents performed 116 major and 77 minor gynecologic surgeries, and teach-assisted Batswana interns and medical officers in 76 cesarean deliveries. Residents led or contributed significantly to 25 didactic education sessions as part of the formal intern OBGYN curriculum. During this period, 24 Batswana interns rotated through the hospital's department of OBGYN, and all 24 trainees met required OBGYN competencies prior to completing their internship.

CONCLUSIONS

Matching US resident demand for global health experiences to equitable global health programming while maintaining ACGME training guidelines poses a challenge to OBGYN residency training programs. This elective provides a model OBGYN global health elective that addresses host-identified needs, broadens residents' skills, and meets standards for postgraduate OBGYN training. Purposeful global health electives for US residents embedded in longitudinal programs provide an opportunity for residents to contribute to broader global health efforts that promote health equity.

The power of peers: an effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

BACKGROUND

Reducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy- or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal.

METHODS

The study was conducted in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized, cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allowed for iterative improvement in design by making changes to improve the quality of the intervention. We evaluated effectiveness through a difference in difference analysis of institutional birth rates between groups prior to implementation of the intervention and 1 year after implementation. Additionally, we assessed the change in knowledge of key danger signs and the acceptability of the group model compared with individual visits in a nested cohort of women receiving home visit care and home visit care plus group antenatal care. Using a directed content and thematic approach, we analyzed qualitative interviews to identify major themes related to implementation.

RESULTS

At baseline, there were 457 recently-delivered women in the six village clusters receiving home visit care and 214 in the seven village clusters receiving home visit care plus group antenatal care. At endline, there were 336 and 201, respectively. The difference in difference analysis did not show a significant change in institutional birth rates nor antenatal care visit completion rates between the groups. There was, however, a significant increase in both institutional birth and antenatal care completion in each group from baseline to endline. We enrolled a nested cohort of 52 participants receiving home visit care and 62 participants receiving home visit care plus group antenatal care. There was high acceptability of the group antenatal care intervention and home visit care, with no significant differences between groups. A significantly higher percentage of women who participated in group antenatal care found their visits to be 'very enjoyable' (83.9% vs 59.6%, p = 0.0056). In the nested cohort, knowledge of key danger signs during pregnancy significantly improved from baseline to endline in the intervention clusters only (2 to 31%, p < 0.001), while knowledge of key danger signs related to labor and childbirth, the postpartum period, and the newborn did not in either intervention or control groups. Qualitative analysis revealed that women found that the groups provided an opportunity for learning and discussion, and the groups were a source of social support and empowerment. They also reported an improvement in services available at their village clinic. Providers noted the importance of the community health workers in identifying pregnant women in the community and linking them to the village clinics. Challenges in birth planning were brought up by both participants and providers.

CONCLUSION

While there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal's adapted group care model demonstrates the potential for impacting women's antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02330887 , registered 01/05/2015, retroactively registered.

ACOG Committee Opinion No. 759: Ethical Considerations for Performing Gynecologic Surgery in Low-Resource Settings Abroad

Global surgical care programs present obstetrician-gynecologists with important opportunities to address disparities in women's health and health care worldwide. However, these programs also present a unique set of practical and ethical challenges. Obstetrician-gynecologists are encouraged to participate in surgical care efforts abroad while taking the necessary steps to ensure that their patients can make informed decisions and receive benefit from and are not harmed by their surgical care. In this document, the Committee on Ethics highlights some of the ethical issues that may arise when providing surgical care in low-resource settings to help guide obstetrician-gynecologists in providing the best care possible. This document has been updated to broaden its focus beyond the example of obstetric fistulae, to address issues pertinent to medical trainees, and to include new information to guide physicians' return home from participation in global surgical care programs. Although clinical research has an important role in the surgical care of patients in global settings, a complete discussion of the conduct of ethical research in global settings is beyond the scope of this document.

Impact of the Saving Mothers, Giving Life Approach on Decreasing Maternal and Perinatal Deaths in Uganda and Zambia

Through district system strengthening, integrated services, and community engagement interventions, the Saving Mothers, Giving Life initiative increased emergency obstetric care coverage and access to, and demand for, improved quality of care that led to rapid declines in district maternal and perinatal mortality. Significant reductions in intrapartum stillbirth rate and maternal mortality ratios around the time of birth attest to the success of the initiative.

Background:

Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions.

Methods:

SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities.

Results:

Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country.

Conclusions:

MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths.

Addressing the First Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Approaches and Results for Increasing Demand for Facility Delivery Services

The Saving Mothers, Giving Life initiative used 3 coordinated approaches to reduce maternal deaths resulting from a delay in deciding to seek health care, known as the “first delay”: (1) promoting safe motherhood messages and facility delivery using radio, theater, and community engagement; (2) encouraging birth preparedness and increasing demand for facility delivery through community outreach worker visits; and (3) providing clean delivery kits and transportation vouchers to reduce financial barriers for facility delivery. These approaches can be adapted in other low-resource settings to reduce maternal and perinatal mortality.

Saving Mothers, Giving Life (SMGL), a 5-year initiative implemented in selected districts in Uganda and Zambia, was designed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care at birth. While originally the “Three Delays” model was designed to focus on curative services that encompass emergency obstetric care, SMGL expanded its application to primary and secondary prevention of obstetric complications. Prevention of the “first delay” focused on addressing factors influencing the decision to seek delivery care at a health facility. Numerous factors can contribute to the first delay, including a lack of birth planning, unfamiliarity with pregnancy danger signs, poor perceptions of facility care, and financial or geographic barriers. SMGL addressed these barriers through community engagement on safe motherhood, public health outreach, community workers who identified pregnant women and encouraged facility delivery, and incentives to deliver in a health facility. SMGL used qualitative and quantitative methods to describe intervention strategies, intervention outcomes, and health impacts. Partner reports, health facility assessments (HFAs), facility and community surveillance, and population-based mortality studies were used to document activities and measure health outcomes in SMGL-supported districts. SMGL's approach led to unprecedented community outreach on safe motherhood issues in SMGL districts. About 3,800 community health care workers in Uganda and 1,558 in Zambia were engaged. HFAs indicated that facility deliveries rose significantly in SMGL districts. In Uganda, the proportion of births that took place in facilities rose from 45.5% to 66.8% (47% increase); similarly, in Zambia SMGL districts, facility deliveries increased from 62.6% to 90.2% (44% increase). In both countries, the proportion of women delivering in facilities equipped to provide emergency obstetric and newborn care also increased (from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia). The districts documented declines in the number of maternal deaths due to not accessing facility care during pregnancy, delivery, and the postpartum period in both countries. This reduction played a significant role in the decline of the maternal mortality ratio in SMGL-supported districts in Uganda but not in Zambia. Further work is needed to sustain gains and to eliminate preventable maternal and perinatal deaths.

Did Saving Mothers, Giving Life Expand Timely Access to Lifesaving Care in Uganda? A Spatial District-Level Analysis of Travel Time to Emergency Obstetric and Newborn Care

A spatial analysis of facility accessibility, taking into account road networks and environmental constraints on travel, suggests that the Saving Mothers, Giving Life (SMGL) initiative increased access to emergency obstetric and neonatal care in SMGL-supported districts in Uganda. Spatial travel-time analyses can inform policy and program efforts targeting underserved populations in conjunction with the geographic distribution of maternity services.

Introduction:

Interventions for the Saving Mothers, Giving Life (SMGL) initiative aimed to ensure all pregnant women in SMGL-supported districts have timely access to emergency obstetric and newborn care (EmONC). Spatial travel-time analyses provide a visualization of changes in timely access.

Methods:

We compared travel-time estimates to EmONC health facilities in SMGL-supported districts in western Uganda in 2012, 2013, and 2016. To examine EmONC access, we analyzed a categorical variable of travel-time duration in 30-minute increments. Data sources included health facility assessments, geographic coordinates of EmONC facilities, geolocated population estimates of women of reproductive age (WRA), and other road network and geographic sources.

Results:

The number of EmONC facilities almost tripled between 2012 and 2016, increasing geographic access to EmONC. Estimated travel time to EmONC facilities declined significantly during the 5-year period. The proportion of WRA able to access any EmONC and comprehensive EmONC (CEmONC) facility within 2 hours by motorcycle increased by 18% (from 61.3% to 72.1%, P < .01) and 37% (from 51.1% to 69.8%, P < .01), respectively from baseline to 2016. Similar increases occurred among WRA accessing EmONC and CEmONC respectively if 4-wheeled vehicles (14% and 31% increase, P < .01) could be used. Increases in timely access were also substantial for nonmotorized transportation such as walking and/or bicycling.

Conclusions:

Largely due to the SMGL-supported expansion of EmONC capability, timely access to EmONC significantly improved. Our analysis developed a geographic outline of facility accessibility using multiple types of transportation. Spatial travel-time analyses, along with other EmONC indicators, can be used by planners and policy makers to estimate need and target underserved populations to achieve further gains in EmONC accessibility. In addition to increasing the number and geographic distribution of EmONC facilities, complementary efforts to make motorized transportation available are necessary to achieve meaningful increases in EmONC access.

Health facility service availability and readiness to provide basic emergency obstetric and newborn care in a low-resource setting: evidence from a Tanzania National Survey

OBJECTIVE

This study used a nationally representative sample from Tanzania as an example of low-resource setting with a high burden of maternal and newborn deaths, to assess the availability and readiness of health facilities to provide basic emergency obstetric and newborn care (BEmONC) and its associated factors.

DESIGN

Health facility-based cross-sectional survey.

SETTING

We analysed data for obstetric and newborn care services obtained from the 2014-2015 Tanzania Service Provision Assessment survey, using WHO-Service Availability and Readiness Assessment tool.

PRIMARY AND SECONDARY OUTCOME MEASURES

Availability of seven signal functions was measured based on the provision of 'parental administration of antibiotic', 'parental administration of oxytocic', 'parental administration of anticonvulsants', 'assisted vaginal delivery', 'manual removal of placenta', 'manual removal of retained products of conception' and 'neonatal resuscitation'. Readiness was a composite variable measured based on the availability of supportive items categorised into three domains: staff training, diagnostic equipment and basic medicines.

RESULTS

Out of 1188 facilities, 905 (76.2%) were reported to provide obstetric and newborn care services and therefore were included in the analysis of the current study. Overall availability of seven signal functions and average readiness score were consistently higher among hospitals than health centres and dispensaries (p<0.001). Furthermore, the type of facility, performing quality assurance, regular reviewing of maternal and newborn deaths, reviewing clients' opinion and number of delivery beds per facility were significantly associated with readiness to provide BEmONC.

CONCLUSION

The study findings show disparities in the availability and readiness to provide BEmONC among health facilities in Tanzania. The Tanzanian Ministry of Health should emphasise quality assurance efforts and systematic maternal and newborn death audits. Health leadership should fairly distribute clinical guidelines, essential medicines, equipment and refresher trainings to improve availability and quality BEmONC.

Strengthening and monitoring health system's capacity to improve availability, utilization and quality of emergency obstetric care in northern Nigeria

BACKGROUND

Quality improvement in emergency obstetric care (EmOC) is a critical and cost-effective suite of interventions for the reduction of maternal and newborn mortality and morbidity. This study was undertaken to evaluate the impact of quality improvement interventions following a baseline assessment in Bauchi state, Nigeria.

METHODS

This was a prospective before and after study between June 2012, and April 2015 in Bauchi State, Nigeria. The surveys included 21 hospitals designated by Ministry of Health (MoH) as comprehensive EmOC centers and 38 primary healthcare centers (PHCs) designated as basic EmOC centers. Data on EmOC services was collected using structured established EmOC tools developed by the Averting Maternal Death and Disability (AMDD), and analyzed using univariate and bivariate statistical analyses.

RESULTS

Facilities providing seven or nine signal EmOC functions increased from 6 (10.2%) in 2012 to 21 (35.6%) in 2015. Basic EmOC facilities increased from 1 (2.6%) to 7 (18.4%) and comprehensive EmOC facilities rose from 3 (14.3%) to 13 (61.9%). Facility birth increased from 3.6% to 8.0%. Cesarean birth rates increased from 3.8% in 2012 to 5.6% in 2015. Met need for EmOC more than doubled from 3.3% in 2012 to 9.9% in 2015. Direct obstetric case fatality rates increased from 3.1% in 2012 to 4.0% in 2015. Major direct obstetric complications as a percent of total maternal deaths was 70.9%, down from 80.1% in 2012.

CONCLUSION

The rise in the percent of facility-based births and in met need for EmOC suggest that interventions recommended and implemented after the baseline study resulted in increased availability, access and utilization of EmOC. Higher patient load, late arrival and better record keeping may explain the associated increase in case fatality rates.

Comparison of pregnancy outcomes between maternity waiting home users and non-users at hospitals with and without a maternity waiting home: retrospective cohort study

Objective

To examine the impact of a maternity waiting home (MWH) by comparing pregnancy outcomes between users and non-users at hospitals with and without an MWH.

Methods

We conducted a retrospective cohort study in Ethiopia comparing one hospital with an MWH (Attat) to a second hospital without one (Butajira). A structured questionnaire among sampled women in 2014 and hospital records from 2011 to 2014 were used to compare sociodemographic characteristics and pregnancy outcomes between Attat MWH users and non-MWH users, Attat MWH users and Butajira, and Attat non-MWH users and Butajira. χ2 or ORs with 95% CIs were calculated.

Results

Compared with Attat non-MWH users (n=306) and Butajira women (n=153), Attat MWH users (n=244) were more often multiparous (multipara vs primigravida: OR 4.43 [95% CI 2.94 to 6.68] and OR 3.58 [95% CI 2.24 to 5.73]), less educated (no schooling vs secondary school: OR 2.62 [95% CI 1.53 to 4.46] and OR 5.21 [95% CI 2.83 to 9.61], primary vs secondary school: OR 4.84 [95% CI 2.84 to 8.25] and OR 5.19 [95% CI 2.91 to 9.27]), poor (poor vs wealthy: OR 8.94 [95% CI 5.13 to 15.61] and OR 12.34 [95% CI 6.78 to 22.44] and further from the hospital (2 h 27 min vs 1 h 00 min and 1 h 12 min: OR 3.08 [95% CI 2.50 to 3.80] and OR 2.18 [95% CI 1.78 to 2.67]). Comparing hospital records of Attat MWH users (n=2784) with Attat non-users (n=5423) and Butajira women (n=9472), maternal deaths were 0 vs 20 (0.4%; p=0.001) and 31 (0.3%; p=0.003), stillbirths 38 (1.4%) vs 393 (7.2%) (OR 0.18 [95% CI 0.13 to 0.25]) and 717 (7.6%) (OR 0.17 [95% CI 0.12 to 0.24]) and uterine ruptures 2 (0.1%) vs 40 (1.1%) (OR 0.05 [95% CI 0.01 to 0.19]) and 122 (1.8%) (OR 0.04 (95% CI 0.01 to 0.16]). No significant differences were found regarding maternal deaths and stillbirths between Attat non-users and Butajira women.

Conclusions

Attat MWH users had less favourable sociodemographic characteristics but better birth outcomes than Attat non-users and Butajira women.

The impact of geographic access on institutional delivery care use in low and middle-income countries: Systematic review and meta-analysis

BACKGROUND

Geographic access to obstetric care facilities has a significant influence on women's uptake of institutional delivery care. However, this effect was not consistent across studies. Some studies reported that geographic access to obstetric care facilities had no influence on the use of facility delivery. Therefore, this systematic review and meta-analysis synthesized and pooled the influence of geographic access on institutional delivery service uptake in low and middle-income countries.

METHODS

Multiple combinations of search terms were used to search articles from six databases and a hand search of reference lists performed. We included observational studies conducted in low and middle-income countries which reported the influence of geographic access on delivery care use. The pooled effects of geographic access on institutional delivery care use were calculated using a random-effects model with a 95% confidence interval.

FINDINGS

In this study a total of 31 studies were included. Among these studies, 15 met criteria for inclusion in the meta-analyses, while the remaining 16 were summarized using qualitative synthesis. Studies included in the analysis where women had to walk 60 minutes or less to access a health facility delivery were significantly heterogeneous. Having access to obstetric care facilities within five kilometres was significantly associated with institutional deliveries (pooled OR = 2.27; 95% CI = 1.82, 2.82). Similarly, a travelling time of 60 minutes or less was significantly associated with higher odds of health facility delivery (pooled OR = 3.30; 95% CI = 1.97, 5.53). Every one-hour and one-kilometre increase in travel time and distance, respectively, was negatively associated with institutional delivery care use.

INTERPRETATION

Geographic access measured in either physical distance and/or travel time was significantly associated with women's use of facility delivery. The greater the distance and/or travel time to obstetric care facilities, the greater the barrier and the lesser the service uptake.

Progress in Mozambique: Changes in the availability, use, and quality of emergency obstetric and newborn care between 2007 and 2012

INTRODUCTION

Maternal mortality in Mozambique has not declined significantly in the last 10-15 years, plateauing around 480 maternal deaths per 100,000 live births. Good quality antenatal care and routine and emergency intrapartum care are critical to reducing preventable maternal and newborn deaths.

MATERIALS AND METHODS

We compare the findings from two national cross-sectional facility-based assessments conducted in 2007 and 2012. Both were designed to measure the availability, use and quality of emergency obstetric and neonatal care. Indicators for monitoring emergency obstetric care were used as were descriptive statistics.

RESULTS

The availability of facilities providing the full range of obstetric life-saving procedures (signal functions) decreased. However, an expansion in the provision of individual signal functions was highly visible in health centers and health posts, but in hospitals, performance was less satisfactory, with proportionally fewer hospitals providing assisted vaginal delivery, obstetric surgery and blood transfusions. All other key indicators showed signs of improvements: the institutional delivery rate, the cesarean delivery rate, met need for emergency obstetric care (EmOC), institutional stillbirth and early neonatal death rates, and cause-specific case fatality rates (CFRs). CFRs for most major obstetric complications declined between 17% and 69%. The contribution of direct causes to maternal deaths decreased while the proportion of indirect causes doubled during the five-year interval.

CONCLUSIONS

The indicator of EmOC service availability, often used for planning and developing EmONC networks, requires close examination. The standard definition can mask programmatic weaknesses and thus, fails to inform decision makers of what to target. In this case, the decline in the use of assisted vaginal delivery explained much of the difference in this indicator between the two surveys, as did faltering hospital performance. Despite this backsliding, many signs of improvement were also observed in this 5-year period, but indicator levels continue below recommended thresholds. The quality of intrapartum care and the adverse consequences from infectious diseases during pregnancy point to priority areas for programmatic improvement.

Facilitators and barriers to birth preparedness and complication readiness in rural Rwanda among community health workers and community members: a qualitative study

BACKGROUND

Birth preparedness and complication readiness (BP/CR) comprise a strategy to make women plan for birth and encourage them to seek professional care in order to reduce poor pregnancy outcome. We aimed to understand the facilitators and barriers to BP/CR among community health workers (CHWs) and community members in rural Rwanda.

METHODS

Eight focus group discussions were conducted with 88 participants comprising of CHWs, elderly women aged 45-68 and men aged 18-59, as well as two key informant interviews in Musanze district, Rwanda, between November and December 2015. Qualitative data were digitally recorded, transcribed verbatim and analysed using content analysis.

RESULTS

Participants perceived the importance of family assistance, medical insurance and attending antenatal care (ANC) to facilitate BP/CR and enhance professional care at birth. CHWs reinforced BP/CR messages by SMS alerts and during community gatherings. 'Ubudehe (collective action to combat poverty)' was known as a tool to identify the poorest families in need of government aid to pay for medical care. Disrespect and abuse of women during labor by health workers were perceived as important barriers to access professional care, as well as conflicting health policies such as user fees for ANC and family planning services, and imposing fines on women giving birth outside health facilities.

CONCLUSION

CHWs, ANC and medical insurance are perceived to be important facilitators of BP/CR. Respectful care is paramount for improved maternal health. There is a need for addressing inconsistent health policies hindering the intention to access professional care.

Linking data sources for measurement of effective coverage in maternal and newborn health: what do we learn from individual- vs ecological-linking methods?

Background

Improving maternal and newborn health requires improvements in the quality of facility-based care. This is challenging to measure: routine data may be unreliable; respondents in population surveys may be unable to accurately report on quality indicators; and facility assessments lack population level denominators. We explored methods for linking access to skilled birth attendance (SBA) from household surveys to data on provision of care from facility surveys with the aim of estimating population level effective coverage reflecting access to quality care.

Methods

We used data from Mayuge District, Uganda. Data from household surveys on access to SBA were linked to health facility assessment census data on readiness to provide basic emergency obstetric and newborn care (BEmONC) in the same district. One individual- and two ecological-linking methods were applied. All methods used household survey reports on where care at birth was accessed. The individual-linking method linked this to data about facility readiness from the specific facility where each woman delivered. The first ecological-linking approach used a district-wide mean estimate of facility readiness. The second used an estimate of facility readiness adjusted by level of health facility accessed. Absolute differences between estimates derived from the different linking methods were calculated, and agreement examined using Lin's concordance correlation coefficient.

Results

A total of 1177 women resident in Mayuge reported a birth during 2012-13. Of these, 664 took place in facilities within Mayuge, and were eligible for linking to the census of the district's 38 facilities. 55% were assisted by a SBA in a facility. Using the individual-linking method, effective coverage of births that took place with an SBA in a facility ready to provide BEmONC was just 10% (95% confidence interval CI 3-17). The absolute difference between the individual- and ecological-level linking method adjusting for facility level was one percentage point (11%), and tests suggested good agreement. The ecological method using the district-wide estimate demonstrated poor agreement.

Conclusions

The proportion of women accessing appropriately equipped facilities for care at birth is far lower than the coverage of facility delivery. To realise the life-saving potential of health services, countries need evidence to inform actions that address gaps in the provision of quality care. Linking household and facility-based information provides a simple but innovative method for estimating quality of care at the population level. These encouraging findings suggest that linking data sets can result in meaningful evidence even when the exact location of care seeking is not known.

Maternal death and delays in accessing emergency obstetric care in Mozambique

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.

Economic evaluation of emergency obstetric care training: a systematic review

Background

Training healthcare providers in Emergency Obstetric Care (EmOC) has been shown to be effective in improving their capacity to provide this critical care package for mothers and babies. However, little is known about the costs and cost-effectiveness of such training. Understanding costs and cost-effectiveness is essential in guaranteeing value-for-money in healthcare spending. This study systematically reviewed the available literature on cost and cost-effectiveness of EmOC trainings.

Methods

Peer-reviewed and grey literature was searched for relevant papers published after 1990. Studies were included if they described an economic evaluation of EmOC training and the training cost data were available. Two reviewers independently searched, screened, and selected studies that met the inclusion criteria, with disagreements resolved by a third reviewer. Quality of studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. For comparability, all costs in local currency were converted to International dollar (I$) equivalents using purchasing power parity conversion factors. The cost per training per participant was calculated. Narrative synthesis was used to summarise the available evidence on cost effectiveness.

Results

Fourteen studies (five full and nine partial economic evaluations) met the inclusion criteria. All five and two of the nine partial economic evaluations were of high quality. The majority of studies (13/14) were from low- and middle-income countries. Training equipment, per diems and resource person allowance were the most expensive components. Cost of training per person per day ranged from I$33 to I$90 when accommodation was required and from I$5 to I$21 when training was facility-based. Cost-effectiveness of training was assessed in 5 studies with differing measures of effectiveness (knowledge, skills, procedure cost and lives saved) making comparison difficult.

Conclusions

Economic evaluations of EmOC training are limited. There is a need to scale-up and standardise processes that capture both cost and effectiveness of training and to agree on suitable economic evaluation models that allow for comparability across settings.

Trial registration

PROSPERO_CRD42016041911.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1586-z) contains supplementary material, which is available to authorized users.

Emergency obstetric and neonatal care needs assessment: Results of the 2010 and 2014 surveys in Burkina Faso

OBJECTIVE

To analyze and compare the availability, utilization, and quality of services for maternal and neonatal health in 2010 and 2014 in Burkina Faso.

METHODS

A cross-sectional study of emergency obstetric and neonatal care services (EmONC) in all public and private health facilities in Burkina Faso in 2010 and a sample of 812 health facilities in 2014. The generic tools developed by the Averting Maternal Death and Disability (AMDD) program were used as the basic tools for evaluation.

RESULTS

In 2010, 25 health facilities were considered as EmONC health facilities and there were 23 in 2014. In 2010 and 2014, the proportion of births in EmONC health facilities was low (4.5%). The cesarean delivery rate also remained very low, at 0.9% in 2010 and 1.13% in 2014. The proportion of obstetric complications supported in health facilities was 12.3% in 2010 and 17.1% in 2014. The direct complication case fatality rate in EmONC health facilities was 1.6% in 2010 and 1.3% in 2014.

CONCLUSION

The two surveys did not show a significant improvement in the availability, utilization, and quality of maternal and neonatal healthcare services between 2010 and 2014.

The scale, scope, coverage, and capability of childbirth care

All women should have access to high quality maternity services-but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

Birth preparedness and place of birth in Tandahimba district, Tanzania: what women prepare for birth, where they go to deliver, and why

Background

As making preparations for birth and health facility delivery are behaviours linked to positive maternal and newborn health outcomes, we aimed to describe what birth preparations were made, where women delivered, and why.

Methods

Outcomes were tabulated using data derived from a repeated sample (continuous) quantitative household survey of women aged 13–49 who had given birth in the past year. Insights into why behaviours took place emerged from analysis of in-depth interviews (12) and birth narratives (36) with recently delivered mothers and male partners.

Results

Five hundred-twenty three women participated in the survey from April 2012–November 2013. Ninety-five percent (496/523) of women made any birth preparations for their last pregnancy. Commonly prepared birth items were cotton gauze (93 %), a plastic cover to deliver on (84 %), gloves (72 %), clean clothes (70 %), and money (42 %). Qualitative data suggest that preparation of items used directly during delivery was perceived as necessary to facilitate good care and prevent disease transmission. Sixty-eight percent of women gave birth at a health facility, 30 % at home, and 2 % on the way to a health facility. Qualitative data suggested that health facility delivery was viewed positively and that women were inclined to go to a health facility because of a perception of: increased education about delivery and birth preparedness; previous health facility delivery; and better availability and accessibility of facilities in recent years. Perceived barriers: were a lack of money; absent health facility staff or poor provider attitudes; women perceiving that they were unable to go to a health facility or arrange transport on their own; or a lack of support of pregnant women from their partners.

Conclusions

The majority of women made at least some birth preparations and gave birth in a health facility. Functional items needed for birth seem to be given precedence over practices like saving money. As such, maintaining education about the importance of these practices, with an emphasis on emergency preparedness, would be valuable. Alongside education delivered as part of focussed antenatal care, community-based interventions that aim to increase engagement of men in birth preparedness, and support agency among women, are recommended.

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

BACKGROUND

Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI).

METHODS

This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression.

RESULTS

Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1·6 per cent at 24 h (high 1·1 per cent, middle 1·9 per cent, low 3·4 per cent; P < 0·001), increasing to 5·4 per cent by 30 days (high 4·5 per cent, middle 6·0 per cent, low 8·6 per cent; P < 0·001). Of the 578 patients who died, 404 (69·9 per cent) did so between 24 h and 30 days following surgery (high 74·2 per cent, middle 68·8 per cent, low 60·5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2·78, 95 per cent c.i. 1·84 to 4·20) and low-income (OR 2·97, 1·84 to 4·81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days.

CONCLUSION

Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role.

REGISTRATION NUMBER

NCT02179112 (http://www.clinicaltrials.gov).

Improved measurement for mothers, newborns and children in the era of the Sustainable Development Goals

BACKGROUND

An urgent priority in maternal, newborn and child health is to accelerate the scale-up of cost-effective essential interventions, especially during labor, the immediate postnatal period and for the treatment of serious infectious diseases and acute malnutrition.  Tracking intervention coverage is a key activity to support scale-up and in this paper we examine priorities in coverage measurement, distinguishing between essential interventions that can be measured now and those that require methodological development.

METHODS

We conceptualized a typology of indicators related to intervention coverage that distinguishes access to care from receipt of an intervention by the population in need.  We then built on documented evidence on coverage measurement to determine the status of indicators for essential interventions and to identify areas for development.

RESULTS

Contact indicators from pregnancy to childhood were identified as current indicators for immediate use, but indicators reflecting the quality of care provided during these contacts need development. At each contact point, some essential interventions can be measured now, but the need for development of indicators predominates around interventions at the time of birth and interventions to treat infections. Addressing this need requires improvements in routine facility based data capture, methods for linking provider and community-based data, and improved guidance for effective coverage measurement that reflects the provision of high-quality care.

CONCLUSION

Coverage indicators for some essential interventions can be measured accurately through household surveys and be used to track progress in maternal, newborn and child health.  Other essential interventions currently rely on contact indicators as proxies for coverage but urgent attention is needed to identify new measurement approaches that directly and reliably measure their effective coverage.

Risk factors for maternal death and trends in maternal mortality in low- and middle-income countries: a prospective longitudinal cohort analysis

Background

Because large, prospective, population-based data sets describing maternal outcomes are typically not available in low- and middle-income countries, it is difficult to monitor maternal mortality rates over time and to identify factors associated with maternal mortality. Early identification of risk factors is essential to develop comprehensive intervention strategies preventing pregnancy-related complications. Our objective was to describe maternal mortality rates in a large, multi-country dataset and to determine maternal, pregnancy-related, delivery and postpartum characteristics that are associated with maternal mortality.

Methods

We collected data describing all pregnancies from 2010 to 2013 among women enrolled in the multi-national Global Network for Women’s and Children’s Health Research Maternal and Neonatal Health Registry (MNHR). We reported the proportion of mothers who died per pregnancy and the maternal mortality ratio (MMR). Generalized linear models were used to evaluate the relationship of potential medical and social factors and maternal mortality and to develop point and interval estimates of relative risk associated with these factors. Generalized estimating equations were used to account for the correlation of outcomes within cluster to develop appropriate confidence intervals.

Results

We recorded 277,736 pregnancies and 402 maternal deaths for an MMR of 153/100,000 live births. We observed an improvement in the total MMR from 166 in 2010 to 126 in 2013. The MMR in Latin American sites (91) was lower than the MMR in Asian (178) and African sites (125). When adjusted for study site and the other variables, no formal education (RR 3.2 [1.5, 6.9]), primary education only (RR 3.4 [1.6, 7.5]), secondary education only (RR 2.5 [1.1, 5.7]), lack of antenatal care (RR 1.8 [1.2, 2.5]), caesarean section delivery (RR 1.9 [1.3, 2.8]), hemorrhage (RR 3.3 [2.2, 5.1]), and hypertensive disorders (RR 7.4 [5.2, 10.4]) were associated with higher risks of death.

Conclusions

The MNHR identified preventable causes of maternal mortality in diverse settings in low- and middle-income countries. The MNHR can be used to monitor public health strategies and determine their association with reducing maternal mortality.

Trial Registration

clinicaltrials.gov NCT01073475