When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country

Prevalence and materno-fetal outcomes of preeclampsia/eclampsia among pregnant women in Nigeria: a systematic review and meta-analysis

BACKGROUND

Preeclampsia and eclampsia (PE/E) are hypertensive disorders of pregnancy with significant morbidity and mortality for both mothers and fetuses. This study aimed to investigate the prevalence of PE/E, associated complications, and mortality rates in pregnant women in Nigeria using a systematic review and meta-analysis approach.

METHODS

A search strategy was employed to identify relevant studies published in English from electronic databases like PubMed, Google Scholar, Science Direct, AJOL, DOAJ and Cochrane Library. Studies investigating the prevalence of PE/E, associated complications, and mortality rates in pregnant women in Nigeria were included. Data extraction and quality assessment were conducted using standardized tools. Pooled prevalence estimates were calculated using random-effects models. Statistical heterogeneity was assessed using the I2 statistic. Publication bias was evaluated using the Egger test.

RESULTS

The analysis revealed a pooled prevalence of 4.51% (95% CI 3.82-5.29) for preeclampsia and 1.39% (95% CI 1.02-1.84) for eclampsia in Nigerian pregnant women. Significant heterogeneity was observed for both PE (I2 = 99.20%, P < 0.001) and eclampsia (I2 = 97.43%, P < 0.001). The pooled maternal mortality rate associated with PE/E was 6.04% (95% CI 3.67-8.89), and the fetal mortality rate was 16.73% (95% CI 12.04-22.00). Analysis of complications associated with PE/E revealed a prevalence of 6.37% (95% CI 3.34-10.22) for acute kidney injury, 3.00% (95% CI 1.43-5.06) for cerebrovascular accident (stroke), 3.98% (95% CI 0.61-9.68) for puerperal sepsis, and 5.26% (95% CI 2.24-9.31) for aspiration pneumonia.

CONCLUSION

This study identified a significant burden of PE/E and associated complications in Nigerian pregnant women. High maternal and fetal mortality rates highlight the critical need for improved strategies in Nigeria. Future research should focus on identifying Nigerian-specific risk factors and implementing standardized diagnostic criteria.

Thinking on the purposes, roles and activities of networks for research on maternal and perinatal health: opinions of coordinators and members

Objective

To identify the opinion of coordinators and members about the essential characteristics and to understand the research networks characteristics, to facilitate their implementation, sustainability and effectiveness so it can be replicated in low and middle-income countries.

Methods

A qualitative study using a semi-structured interview technique was conducted. We selected potential members, managers and participants of networks from publications identified in PubMed. After checking the FIGO congress program, we identified authors who were assigned as speakers at the event. An invitation was sent and interviews were scheduled.

Results

In total, eleven interviews were performed. Coordinators and members of networks have the same goal when they decide to participate in a network. In general, they cited that these individuals had to be committed, responsible and enthusiastic people. The network should be composed also of postgraduate students. A network should allow multi-leadership, co-responsibility, autonomy and empowerment of its members. Effective communication was mentioned as an important pillar for network maintenance. Another motivation is being an author or coauthor in publications. One way to maintain a network running is social or governmental commitment, after resources expire, studies continue.

Conclusion

Networks are different due to the social context where they are inserted, however, some characteristics are common to all of them, such as having engaged leaders. For an effective and sustainable network, commitment and motivation in a leader and members are more in need than financial resources. Ideally, to ensure the operation of the network, the institution where the leader is linked should support this network.

Determinants and outcomes of preterm births in Nigerian tertiary facilities

OBJECTIVE

To describe the incidence, and sociodemographic and clinical factors associated with preterm birth and perinatal mortality in Nigeria.

DESIGN

Secondary analysis of data collected through the Maternal Perinatal Database for Quality, Equity and Dignity (MPD-4-QED) Programme.

SETTING

Data from births in 54 referral-level hospitals across Nigeria between 1 September 2019 and 31 August 2020.

POPULATION

A total of 69 698 births.

METHODS

Multilevel modelling was used to determine the factors associated with preterm birth and perinatal mortality.

OUTCOME MEASURES

Preterm birth and preterm perinatal mortality.

RESULTS

Of 62 383 live births, 9547 were preterm (153 per 1000 live births). Maternal age (<20 years - adjusted odds ratio [aOR] 1.52, 95% CI 1.36-1.71; >35 years - aOR 1.23, 95% CI 1.16-1.30), no formal education (aOR 1.68, 95% CI 1.54-1.84), partner not gainfully employed (aOR 1.94, 95% CI 1.61-2.34) and no antenatal care (aOR 2.62, 95% CI 2.42-2.84) were associated with preterm births. Early neonatal mortality for preterm neonates was 47.2 per 1000 preterm live births (451/9547). Father's occupation (manual labour aOR 1.52, 95% CI 1.20-1.93), hypertensive disorders of pregnancy (aOR 1.37, 95% CI 1.02-1.83), no antenatal care (aOR 2.74, 95% CI 2.04-3.67), earlier gestation (28 to <32 weeks - aOR 2.94, 95% CI 2.15-4.10; 32 to <34 weeks - aOR 1.80, 95% CI 1.3-2.44) and birthweight <1000 g (aOR 21.35, 95% CI 12.54-36.33) were associated with preterm perinatal mortality.

CONCLUSIONS

Preterm birth and perinatal mortality in Nigeria are high. Efforts should be made to enhance access to quality health care during pregnancy, delivery and the neonatal period, and improve the parental socio-economic status.

Risk factors for maternal near-miss in an undeveloped province in south-central China, 2012-2022

OBJECTIVE

To explore the risk factors for maternal near-miss (MNM) using the WHO near-miss approach.

METHODS

Data were obtained from the Maternal Near-Miss Surveillance System in Hunan Province, China, 2012-2022. Multivariate logistic regression analysis (method: Forward, Wald, α = 0.05) and adjusted odds ratios (aORs) were used to identify risk factors for MNM.

RESULTS

Our study included 780,359 women with 731,185 live births, a total of 2461 (0.32%) MNMs, 777,846 (99.68%) non-MNMs, and 52 (0.006%) maternal deaths were identified. The MNM ratio was 3.37‰ (95%CI: 3.23-3.50). Coagulation/hematological dysfunction was the most common cause of MNM (75.66%). Results of multivariate logistic regression analysis showed risk factors for MNM: maternal age > = 30 years old (aOR > 1, P < 0.05), unmarried women (aOR = 2.21, 95%CI: 1.71-2.85), number of pregnancies > = 2 (aOR > 1, P < 0.05), nulliparity (aOR = 1.51, 95%CI: 1.32-1.72) or parity > = 3 (aOR = 1.95, 95%CI: 1.50-2.55), prenatal examinations < 5 times (aOR = 1.13, 95%CI: 1.01-1.27), and number of cesarean sections was 1 (aOR = 1.83, 95%CI: 1.64-2.04) or > = 2 (aOR = 2.48, 95%CI: 1.99-3.09).

CONCLUSION

The MNM ratio was relatively low in Hunan Province. Advanced maternal age, unmarried status, a high number of pregnancies, nulliparity or high parity, a low number of prenatal examinations, and cesarean sections were risk factors for MNM. Our study is essential for improving the quality of maternal health care and preventing MNM.

Outcomes of a multifaceted intervention to prevent eclampsia and eclampsia-related deaths in Nigerian referral facilities

BACKGROUND

Eclampsia causes maternal mortality in Nigeria. This study presents the effectiveness of multifaceted interventions that addressed institutional barriers in reducing the incidence and case fatality rates associated with eclampsia.

METHODS

The design was quasi-experimental and the activities implemented at intervention hospitals included a new strategic plan, retraining health providers on eclampsia management protocols, clinical reviews of delivery care and educating pregnant women and their partners. Prospective data were collected monthly on eclampsia and related indicators from study sites over 2 y. The results were analysed by univariate, bivariate and multivariable logistic regression.

RESULTS

The results show a higher eclampsia rate (5.88% vs 2.45%) and a lower use of partograph and antenatal care (ANC; 17.99% vs 23.42%) in control compared with intervention hospitals, but similar case fatality rates of <1%. Overall, adjusted analysis shows a 63% decrease in the odds of eclampsia at intervention compared with control hospitals. Factors associated with eclampsia were ANC, referral for care from other facilities and older maternal age.

CONCLUSION

We conclude that multifaceted interventions that address challenges associated with managing pre-eclampsia and eclampsia in health facilities can reduce eclampsia occurrence in referral facilities in Nigeria and potential eclampsia death in resource-poor African countries.

A population-based estimation of maternal mortality in Lagos State, Nigeria using the indirect sisterhood method

BACKGROUND

Pregnancy and delivery deaths represent a risk to women, particularly those living in low- and middle-income countries (LMICs). This population-based survey was conducted to provide estimates of the maternal mortality ratio (MMR) in Lagos Nigeria.

METHODS

A community-based, cross-sectional study was conducted in mapped Wards and Enumeration Areas (EA) of all Local Government Areas (LGAs) in Lagos, among 9,986 women of reproductive age (15-49 years) from April to August 2022 using a 2-stage cluster sampling technique. A semi-structured, pre-tested questionnaire adapted from nationally representative surveys was administered using REDCap by trained field assistants for data collection on socio-demographics, reproductive health, fertility, and maternal mortality. Data were analysed using SPSS and MMR was estimated using the indirect sisterhood method. Ethical approval was obtained from the Lagos State University Teaching Hospital Health Research and Ethics Committee.

RESULTS

Most of the respondents (28.7%) were aged 25-29 years. Out of 546 deceased sisters reported, 120 (22%) died from maternal causes. Sisters of the deceased aged 20-24 reported almost half of the deaths (46.7%) as due to maternal causes, while those aged 45-49 reported the highest number of deceased sisters who died from other causes (90.2%). The total fertility rate (TFR) was calculated as 3.807, the Lifetime Risk (LTR) of maternal death was 0.0196 or 1-in-51, and the MMR was 430 per 100,000 [95% CI: 360-510].

CONCLUSION

Our findings show that the maternal mortality rate for Lagos remains unacceptable and has not changed significantly over time in actual terms. There is need to develop and intensify community-based intervention strategies, programs for private hospitals, monitor MMR trends, identify and contextually address barriers at all levels of maternal care.

Urinary Nephrin Levels Among Pregnant Women With Preeclampsia in Lagos, Southwest Nigeria: An Analytical Cross-Sectional Study

BACKGROUND

Hypertensive disorders in pregnancy are one of the leading causes of maternal and perinatal morbidity and mortality worldwide. The clinical utility of urinary nephrin as a diagnostic biomarker of preeclampsia is currently of research interest. However, this is yet to gain significant traction within clinical settings.

OBJECTIVES

We evaluated the association between maternal urinary nephrin levels and the occurrence and severity of preeclampsia among pregnant women in Lagos, Nigeria.

DESIGN

We conducted an analytical cross-sectional study involving pregnant women diagnosed with preeclampsia as well as their age- and gestational-age-matched normotensive counterparts. We tested the association between high maternal urinary nephrin levels and the occurrence of preeclampsia without and with severe features. P < 0.05 was reported as statistically significant.

RESULTS

The study showed that for every unit increase in urinary nephrin levels, the odds of preeclampsia increased by about ninefold (adjusted Odds ratio = 8.9, 95% confidence interval: 2.8-29.2, P < 0.001). The levels of urinary nephrin increased steadily with increasing severity of the disease: 1.9 ± 0.8 ng/mL in preeclampsia without severe features, 2.7 ± 0.7 ng/mL in preeclampsia with at least one severe feature, and 3.3 ±1.1 ng/mL in eclampsia.

CONCLUSION

There was an association between elevated levels of urinary nephrin and preeclampsia and its severe variant. However, there is a need for more robust studies with a longitudinal characterization of urinary nephrin levels to establish causal relationships with preeclampsia, explore other potential risk factors of preeclampsia, and define the clinical usefulness of urinary nephrin as a potentially reliable and accurate predictive marker of preeclampsia among women in low- and middle-income countries (LMIC) settings.

Prevalence of non-communicable diseases and risk factors of pre-eclampsia/eclampsia in four local government areas in Nigeria: a cross-sectional study

OBJECTIVES

To assess the prevalence of non-communicable diseases (NCDs) and risk factors associated with pre-eclampsia and eclampsia (PE/E) in women of reproductive age (WRA) in Nigeria.

DESIGN

A cross-sectional survey was administered to the entire study population. In the point-of-care testing, physical and biochemical measurements were taken in a subset of the participants.

SETTING

The study was conducted in the Ikorodu and Alimosho local government areas (LGAs) in Lagos and the Abuja Municipal Area Council and Bwari LGAs in the Federal Capital Territory.

PARTICIPANTS

Systematic random sampling was used to randomly select and recruit 639 WRA (aged 18-49 years) between May 2019 and June 2019.

OUTCOME MEASURES

Prevalence of select NCDs (hypertension or raised blood pressure, diabetes or raised blood sugar levels, anaemia, truncal obesity and overweight/obesity) and risk factors associated with PE/E (physical activity, fruit and vegetable consumption, alcohol consumption and smoking).

RESULTS

The prevalence of raised blood pressure measured among the WRA was 36.0% (95% CI 31.3% to 40.9%). Approximately 10% (95% CI 7.2% to 13.4%) of participants had raised blood sugar levels. About 19.0% (95% CI 15.3% to 23.2%) of the women had moderate or severe anaemia. Excluding WRA who were pregnant, 51.9% (95% CI 45.7% to 58.0%) of the women were either overweight or obese based on their body mass index. Approximately 58.8% (95% CI 53.8% to 63.6%) of WRA surveyed reported three to five risk factors for developing NCDs and PE/E in future pregnancies.

CONCLUSIONS

The study identified a high prevalence of NCDs and associated PE/E risk factors in surveyed women, signifying the importance of early detection and intervention for modifiable NCD and associated PE/E risk factors in WRA. Further research is necessary to assess the national prevalence of NCDs.

A comparative study on the effectiveness of paracervical block and parenteral diclofenac for pain relief during manual vacuum aspiration

Objective

To compare the effectiveness of paracervical block with intramuscular Diclofenac for pain relief during manual vacuum aspiration (MVA) for early pregnancy losses.

Methodology

This was an open label randomized controlled trial. Participants were randomized into two therapeutic groups (A and B) using computer generated numbers. Group A received intramuscular Diclofenac 75 mg. Group B received paracervical block using 1% Lidocaine. Participants were asked to rate their pain level on a continuous 10 cm visual analogue scale (VAS) from 0 (no pain) to 10 (the worst pain ever) within 5 minutes of completing the procedure. Participants' level of satisfaction was assessed within 30 minutes of completing the MVA using Likert scale. Data was analysed using the Statistical Package for Social Sciences (SPSS), Version 20. Test of statistical significance was set at 95% confidence level (P < 0.05). The primary outcome was the level of pain felt by the patient during the procedure (10 cm VAS). Secondary outcomes included patient's satisfaction and adverse events.

Results

There was significant difference in the mean pain level between the intramuscular diclofenac group; 6.5±1.5 (moderate) and those that received paracervical block; 2.3±1.5 (mild), (p-value=0.005). Patients' satisfaction was also better in paracervical block group compared to intramuscular diclofenac group, (p-value=0.005). Both groups were comparable in terms of complications and drug side effects.

Conclusion

Findings from the study suggest that the use of paracervical block compared to intramuscular Diclofenac for pain relief during MVA for incomplete miscarriage significantly reduced pain, improved patients' satisfaction and was comparably safe.

Global Stillbirth Policy Review - Outcomes And Implications Ahead of the 2030 Sustainable Development Goal Agenda

BACKGROUND

Globally, data on stillbirth is limited. A call to action has been issued to governments to address the data gap by strengthening national policies and strategies to drive urgent action on stillbirth reduction. This study aims to understand the policy environment for stillbirths to advance stillbirth recording and reporting in data systems.

METHODS

A systematic three-step process (survey tool examination, identifying relevant study questions, and reviewing country responses to the survey and national documents) was taken to review country responses to the global 2018-2019 World Health Organization (WHO) Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy Survey. Policy Survey responses were reviewed to identify if and how stillbirths were included in national documents. This paper uses descriptive analyses to identify and describe the relationship between multiple variables.

RESULTS

Responses from 155 countries to the survey were analysed, and over 800 national policy documents submitted by countries in English reviewed. Fewer than one-fifth of countries have an established stillbirth rate (SBR) target, with higher percentages reported for under-5 (71.0%) and neonatal mortality (68.5%). Two-thirds (65.8%) of countries reported a national maternal death review panel. Less than half (43.9%) of countries have a national policy that requires stillbirths to be reviewed. Two-thirds of countries have a national policy requiring review of neonatal deaths. WHO websites and national health statistics reports are the common data sources for stillbirth estimates. Countries that are signatories to global initiatives on stillbirth reduction have established national targets. Globally, nearly all countries (94.8%) have a national policy that requires every death to be registered. However, 45.5% of reviewed national policy documents made mention of registering stillbirths. Only 5 countries had national policy documents recommending training of health workers in filling out death certificates using the International Classification of Diseases (ICD)-10 for stillbirths.

CONCLUSION

The current policy environment in countries is not supportive for identifying stillbirths and recording causes of death. This is likely to contribute to slow progress in stillbirth reduction. The paper proposes policy recommendations to make every baby count.

High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study)

BACKGROUND

Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR).

METHODS

We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records' reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity.

RESULTS

We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%).

CONCLUSION

Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.

Examining maternal morbidity across a spectrum of delivery locations: An analysis of the Global Network's Maternal and Neonatal Health Registry

OBJECTIVE

To better understand maternal morbidity, using quality data from low- and middle-income countries (LMICs), including out-of-hospital deliveries. Additionally, to compare to the WHO estimate that maternal morbidity occurs in 15% of pregnancies, which is based largely on hospital-level data.

METHODS

The Global Network for Women's and Children's Health Research Maternal Newborn Health Registry collected data on all pregnancies from seven sites in six LMICs between 2015 and 2020. Rates of maternal mortality and morbidity and the differences in morbidity across delivery location and birth attendant type were evaluated.

RESULTS

Among the 280 584 deliveries included in the present analysis, the overall maternal mortality ratio was 138 per 100 000, while 11.7% of women experienced at least one morbidity. Rates of morbidity were generally higher for deliveries occurring within hospitals (19.8%) and by physicians (23.6%). The lowest rates of morbidity were noted among women delivering in non-hospital healthcare facilities (5.6%) or with non-physician clinicians (e.g. nurses, midwives [5.4%]).

CONCLUSION

The present study shows important differences in reported maternal morbidity across delivery sites, with a trend towards lower morbidity in non-hospital healthcare facilities and among non-physician clinicians.

Equity in provision and access to obstetric anaesthesia care in Nigeria

Nigeria has a high maternal mortality rate, yet there is wide variation in the proportion of births by caesarean section between zones, states, and cities within Nigeria. This review examines the pattern of the COVID-19 pandemic and the impact of mitigation measures on women's health in Nigeria. The combined impact of COVID-19 and conflicts on maternal healthcare and access to obstetric care, as well as the availability of obstetric anaesthesia in Nigeria, are discussed. There is a vicious cycle, intensified by unwanted pregnancy, abortion, and preventable maternal death.

A Comparative Study of the Efficacy of Intraoperative Intravenous Oxytocin and Intramuscular Oxytocin Versus Conventional Intramuscular Oxytocin for Third-Stage Labour in Elective Cesarean Section

Objective  To study the efficacy of intraoperative IV oxytocin and intramuscular (IM) oxytocin versus conventional intramuscular oxytocin alone for active management of the third stage of labor in lower segment cesarean section (CS). The study was performed to determine the effect of 5 IU (International Unit) oxytocin infusion at the time of skin incision and that of 10 IU IM oxytocin infusion after delivery in reducing blood loss during and after CS, in comparison with the effect of administrating conventional 10 IU IM oxytocin in the same time period. In addition, it assessed the ability of the IV+IM oxytocin group to reduce the need for additional uterotonic as well as its safety determination and postoperative blood transfusion in CS. Materials and methods It is a randomized control study. The effect of 5 IU of oxytocin infusion at the time of skin incision and 10 IU of IM oxytocin (IV+IM) in reducing blood loss during and after the CS was compared to conventional 10 IU IM oxytocin. Results The study showed that the IV+IM group had a mean blood loss of 316.5 ± 74.36 ml, while the IM group had a mean loss of 403.90 ± 107.2 ml (p-value < 0.001) from placental delivery to the end of CS. A total of 90% of the patients in the IV+IM group had blood loss <50 ml compared to 95% of patients in the IM group who had a blood loss between 50 and 100 ml range from the end of cesarean to two hours postpartum. When total blood loss was compared in both groups, 84% of patients had a blood loss between 300 and 400 ml, compared to 81% of the patients in the IM group who had blood loss of 400-500 ml. Total blood loss in the IM group was 483.20 ± 115.86 ml, which was significantly higher compared to the IV group, 362.60 ± 78.07 ml (p-value=<0.001). Conclusion 5IU oxytocin infusion at the time of skin incision and 10 IU IM oxytocin after delivery of the baby significantly reduced the amount of blood loss, need for blood transfusion, and additional uterotonics during and after lower segment CS.

Neurological disorders in pregnant women in low- and middle-income countries-Management gaps, impacts, and future prospects: A review perspective

Neurological disorders during pregnancy are a substantial threat to women's health, particularly in low- and middle-income countries. Furthermore, a critical shortage of mental health workers and neurologists exacerbates the already pressing issue, where a lack of coordination of respective healthcare among multidisciplinary teams involved in managing these conditions perpetuates the current state of affairs. Financial restrictions and societal stigmas associated with neurological disorders in pregnancy amplify the situation. Addressing these difficulties would necessitate a multifaceted approach comprising investments in healthcare infrastructure, healthcare professional education and training, increased government support for research, and the implementation of innovative care models. Improving access to specialized treatment and coordinated management of antenatal neurological diseases will precipitate improved health outcomes for women and their families in low- and middle-income countries.

Predictors and causes of in-hospital maternal deaths within 120 h of admission at a tertiary hospital in South-Western, Nigeria: A retrospective cohort study

Background

An efficient, comprehensive emergency obstetrics care (CEMOC) can considerably reduce the burden of maternal mortality (MM) in Nigeria. Information about the risk of maternal death within 120 h of admission can reflect the quality of CEMOC offered.

Aim

This study aims to determine the predictors and causes of maternal death within 120 h of admission at the Lagos University Teaching Hospital, LUTH, Lagos South-Western, Nigeria.

Methods

We conducted a retrospective cohort study amongst consecutive maternal deaths at a hospital in South-Western Nigeria, from 1 January 2007 to 31 December 2017, using data from patients' medical records. We compared participants that died within 120 h to participants that survived beyond 120 h. Survival life table analysis, Kaplan-Meier plots and multivariable Cox proportional hazard regression were conducted to evaluate the factors affecting survival within 120 h of admission. Stata version 16 statistical software (StatCorp USA) was used for analysis.

Results

Of the 430 maternal deaths, 326 had complete records. The mean age of the deceased was 30.7± (5.9) years and median time to death was 24 (5-96) h. Two hundred and sixty-eight (82.2%) women out of 326 died within 120 h of admission. Almost all maternal deaths from uterine rupture (95.2%) and most deaths from obstetric haemorrhage (87.3%), induced miscarriage (88.9%), sepsis (82.9%) and hypertensive disorders of pregnancy (77.9%) occurred within 120 h of admission. Admission to the intensive care unit (P = 0.007), cadre of admitting doctor (P < 0.001), cause of death (P = 0.036) and mode of delivery (P = 0.012) were independent predictors of hazard of death within 120 h.

Conclusion

The majority (82.2%) of maternal deaths occurred within 120 h of admission. Investment in the prevention and acute management of uterine rupture, obstetric haemorrhage, sepsis and hypertensive disorders of pregnancy can help to reduce MM within 120 h in our environment.

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

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

Quality and outcomes of maternal and perinatal care for 76,563 pregnancies reported in a nationwide network of Nigerian referral-level hospitals

BACKGROUND

The WHO in collaboration with the Nigeria Federal Ministry of Health, established a nationwide electronic data platform across referral-level hospitals. We report the burden of maternal, foetal and neonatal complications and quality and outcomes of care during the first year.

METHODS

Data were analysed from 76,563 women who were admitted for delivery or on account of complications within 42 days of delivery or termination of pregnancy from September 2019 to August 2020 across the 54 hospitals included in the Maternal and Perinatal Database for Quality, Equity and Dignity programme.

FINDINGS

Participating hospitals reported 69,055 live births, 4,498 stillbirths and 1,090 early neonatal deaths. 44,614 women (58·3%) had at least one pregnancy complication, out of which 6,618 women (8·6%) met our criteria for potentially life-threatening complications, and 940 women (1·2%) died. Leading causes of maternal death were eclampsia (n = 187,20·6%), postpartum haemorrhage (PPH) (n = 103,11·4%), and sepsis (n = 99,10·8%). Antepartum hypoxia (n = 1455,31·1%) and acute intrapartum events (n = 913,19·6%) were the leading causes of perinatal death. Predictors of maternal and perinatal death were similar: low maternal education, lack of antenatal care, referral from other facility, previous caesarean section, latent-phase labour admission, operative vaginal birth, non-use of a labour monitoring tool, no labour companion, and non-use of uterotonic for PPH prevention.

INTERPRETATION

This nationwide programme for routine data aggregation shows that maternal and perinatal mortality reduction strategies in Nigeria require a multisectoral approach. Several lives could be saved in the short term by addressing key predictors of death, including gaps in the coverage of internationally recommended interventions such as companionship in labour and use of labour monitoring tool.

FUNDING

This work was funded by MSD for Mothers; and UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization (WHO).

Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study

Introduction

Prompt access to emergency obstetrical care (EmOC) reduces the risk of maternal mortality. We assessed institutional maternal mortality by distance and travel time for pregnant women with obstetrical emergencies in Lagos State, Nigeria.

Methods

We conducted a facility-based retrospective cohort study across 24 public hospitals in Lagos. Reviewing case notes of the pregnant women presenting between 1 November 2018 and 30 October 2019, we extracted socio-demographic, travel and obstetrical data. The extracted travel data were exported to Google Maps, where driving distance and travel time data were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on maternal death.

Findings

Of 4181 pregnant women with obstetrical emergencies, 182 (4.4%) resulted in maternal deaths. Among those who died, 60.3% travelled ≤10 km directly from home, and 61.9% arrived at the hospital ≤30 mins. The median distance and travel time to EmOC was 7.6 km (IQR 3.4–18.0) and 26 mins (IQR 12–50). For all women, travelling 10–15 km (2.53, 95% CI 1.27 to 5.03) was significantly associated with maternal death. Stratified by referral, odds remained statistically significant for those travelling 10–15 km in the non-referred group (2.48, 95% CI 1.18 to 5.23) and for travel ≥120 min (7.05, 95% CI 1.10 to 45.32). For those referred, odds became statistically significant at 25–35 km (21.40, 95% CI 1.24 to 36.72) and for journeys requiring travel time from as little as 10–29 min (184.23, 95% CI 5.14 to 608.51). Odds were also significantly higher for women travelling to hospitals in suburban (3.60, 95% CI 1.59 to 8.18) or rural (2.51, 95% CI 1.01 to 6.29) areas.

Conclusion

Our evidence shows that distance and travel time influence maternal mortality differently for referred women and those who are not. Larger scale research that uses closer-to-reality travel time and distance estimates as we have done, rethinking of global guidelines, and bold actions addressing access gaps, including within the suburbs, will be critical in reducing maternal mortality by 2030.

Assessing service quality and the perceptual difference between employees and patients of public hospitals in a developing country

Purpose

This study aims to examine service quality in Nigerian general hospitals and determines possible differences in service quality perceptions between employees and patients.

Design/methodology/approach

Using the Servqual scale, data was collected from 328 employees and patients of two government hospitals in Abuja and Delta states. Analysis was carried out using SPSS 26 package for constructs reliability frequency, mean, standard deviation and t-statistics.

Findings

The study found significant differences in the perception of service quality between employees and patients of the Nigerian general hospitals. While employees gave a high rating to empathy, patients rated it low. Also, the patients’ poor perception of tangible did not match the employees’ high perception. Other specific findings are patients’ unfavourable assessment of the physical facilities and judged the staff to lack professional dressing. Patients felt the hospitals could not provide necessary equipment for their procedures and thus considered their services unreliable.

Practical implications

Reliability was perceived as a significant problem in this study; therefore, the hospitals management should ensure correct diagnoses and treatment results of the highest quality and timely services. Also, the management should invoke strong relationships between the employees and patients to earn patients’ trust. Employees should ensure to listen to patients’ complaints and find solutions promptly. Patients need health-care workers’ support and rely on their abilities; Therefore, health-care workers should be highly dependable and show empathic behaviour in discharging their duties. Health-care managers must access employees‘ and patients’ particular perceptual gaps and reconcile the difference before further quality improvement initiatives.

Originality/value

The findings in this study strengthen the clamour for assessing service quality from both employees and patients’ views in public hospitals. Hospital service quality is complex and primarily judged from the patients’ perspective. This study showed that health-care quality means different things to all stakeholders.

Global and regional estimates of maternal near miss: a systematic review, meta-analysis and experiences with application

Introduction

Maternal near miss (MNM) is a useful means to examine quality of obstetric care. Since the introduction of the WHO MNM criteria in 2011, it has been tested and validated, and is being used globally. We sought to systematically review all available studies using the WHO MNM criteria to develop global and regional estimates of MNM frequency and examine its application across settings.

Methods

We conducted a systematic review by implementing a comprehensive literature search from 2011 to 2018 in six databases with no language restrictions. The predefined data collection tool included sections on study characteristics, frequency of near-miss cases and study quality. Meta-analysis was performed by regional groupings. Reported adaptations, modifications and remarks about application were extracted.

Results

7292 articles were screened by title and abstract, and 264 articles were retrieved for full text review for the meta-analysis. An additional 230 articles were screened for experiences with application of the WHO MNM criteria. Sixty studies with near-miss data from 56 countries were included in the meta-analysis. The pooled global near-miss estimate was 1.4% (95% CI 0.4% to 2.5%) with regional variation in MNM frequency. Of the 20 studies that made adaptations to the criteria, 19 were from low-resource settings where lab-based criteria were adapted due to resource limitations.

Conclusions

The WHO MNM criteria have enabled the comparison of global and sub-national estimates of MNM frequency. There has been good uptake in low-resource countries but contextual adaptations are necessary.

Trend and decomposition analysis of risk factors of childbirths with no one present in Nigeria, 1990-2018

OBJECTIVES

To assess the trend and decompose the determinants of delivery with no one present (NOP) at birth with an in-depth subnational analysis in Nigeria.

DESIGN

Cross-sectional.

SETTING

Nigeria, with five waves of nationally representative data in 1990, 2003, 2008, 2013 and 2018.

PARTICIPANTS

Women with at least one childbirth within 5 years preceding each wave of data collection.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome of interest is giving birth with NOP at delivery defined as childbirth assisted by no one. Data were analysed using Χ² and multivariate decomposition analyses at a 5% significance level.

RESULTS

The prevalence of having NOP at delivery was 15% over the studied period, ranges from 27% in 1990 to 11% in 2018. Overall, the prevalence of having NOP at delivery reduced significantly by 35% and 61% within 2003-2018 and 1990-2018, respectively (p<0.001). We found wide variations in NOP across the states in Nigeria. The highest NOP practice was in Zamfara (44%), Kano (40%) and Katsina (35%); while the practice was 0.1% in Bayelsa, 0.8% in Enugu, 0.9% in Osun and 1.1% in Imo state. The decomposition analysis of the changes in having NOP at delivery showed that 85.4% and 14.6% were due to differences in women's characteristics (endowment) and effects (coefficient), respectively. The most significant contributions to the changes were the decision-maker of healthcare utilisation (49%) and women educational status (24%). Only Gombe experienced a significant increase (p<0.05) in the level of having NOP between 2003 and 2018.

CONCLUSION

A long-term decreasing secular trend of NOP at delivery was found in Nigeria. NOP is more prevalent in the northern states than in the south. Achieving zero prevalence of NOP at delivery in Nigeria would require a special focus on healthcare utilisation, enhancing maternal education and healthcare utilisation decision-making power.

Causes of maternal mortality in Sub-Saharan Africa: A systematic review of studies published from 2015 to 2020

Background

Maternal deaths remain high in Sub-Saharan Africa (SSA) and their causes of maternal death must be analysed frequently in this region to guide interventions.

Methods

We conducted a systematic review of studies published from 2015 to 2020 that reported the causes of maternal deaths in 57 SSA countries. The objective was to identify the leading causes of maternal deaths using the international classification of disease - 10^th revision, for maternal mortality (ICD-MM). We searched PubMed, WorldCat Discovery Libraries Worldwide (including Medline, Web of Science, LISTA and CNHAL databases), and Google Scholar databases and citations, using the search words "maternal mortality", "maternal death", "pregnancy-related death", "reproductive age mortality" and "causes" as MeSH terms or keywords. The last date of search from all databases was 21 May 2021. We included original research articles published in English and excluded articles that mentioned SSA country names without study results for those countries, studies that reported death from a single cause or assigned causes of death using computer models or incompletely broke down the causes of death. We exported, de-duplicated and screened the searches electronically in EndNote version 20. We selected the final articles by reading the titles, abstracts and full texts. Two authors searched the articles and assessed the risk of bias using a tool adapted from Montoya and others. Data from the articles were extracted onto an Excel worksheet and the deaths classified into ICD-MM groups. Proportions were calculated with 95% confidence intervals and compared for deaths attributed to each cause and ICD-MM group. We compared the results with WHO and Global Burden of Disease (GDB) estimates.

Results

We identified 38 studies that reported 11 427 maternal and four incidental deaths. Twenty-one of the third-eight studies were retrospective record reviews. The leading causes of death (proportions and 95% confidence intervals (CI)) were obstetric hemorrhage: 28.8% (95% CI = 26.5%-31.2%), hypertensive disorders in pregnancy: 22.1% (95% CI = 19.9%-24.2%), non-obstetric complications: 18.8% (95% CI = 16.4%-21.2%) and pregnancy-related infections: 11.5% (95% CI = 9.8%-13.2%). The studies reported few deaths of unknown/undetermined and incidental causes.

Conclusions

Limitations of this review were the failure to access more data from government reports, but the study results compared well with WHO and GDB estimates. Obstetric hemorrhage, hypertensive disorders in pregnancy, non-obstetric complications, and pregnancy-related infections are the leading causes of maternal deaths in SSA. However, deaths from incidental causes are likely under-reported in this region. SSA countries must continue to invest in health information systems that collect and publishes comprehensive, quality, maternal death causes data. A publicly accessible repository of data sets and government reports for causes of maternal death will be helpful in future reviews. This review received no specific funding and was not registered.

Patterns, travel to care and factors influencing obstetric referral: Evidence from Nigeria's most urbanised state

The criticality of referral makes it imperative to study its patterns and factors influencing it at a health systems level. This study of referral in Lagos, Nigeria is based on health records of 4181 pregnant women who presented with obstetric emergencies at one of the 24 comprehensive emergency obstetric care (EmOC) facilities in the state between November 2018 and October 2019 complemented with distance and time data extracted from Google Maps. Univariate, bivariate, and multivariate analyses were conducted. About a quarter of pregnant women who presented with obstetric emergencies were referred. Most referrals were from primary health centres (41.9 %), private (23.5 %) and public (16.2 %) hospitals. Apart from the expected low-level to high-level referral pattern, there were other patterns observed including non-formal, multiple, and post-delivery referrals. Travel time and distance to facilities that could provide needed care increased two-fold on account of referrals compared to scenarios of going directly to the final facility, mostly travelling to these facilities by private cars/taxis (72.8 %). Prolonged/obstructed labour was the commonest obstetric indication for referral, with majority of referred pregnant women delivered via caesarean section (52.9 %). After adjustment, being married, not being registered for antenatal care at facility of care, presenting at night or with a foetus in distress increased the odds of referral. However, parity, presentation in the months following the commissioning of a new comprehensive EmOC facility or with abortion reduced the likelihood of being referred. Our findings underscore the need for health systems strengthening interventions that support women during referral and the importance of antenatal care and early booking to aid identification of potential pregnancy complications whilst establishing robust birth preparedness plans that can minimise the need for referral in the event of emergencies. Indeed, there are context-specific influences that need to be addressed if effective referral systems are to be designed.

Prevalence and materno-fetal outcomes of preeclampsia/eclampsia amongst pregnant women at a teaching hospital in north-central Nigeria: a retrospective cross-sectional study

Background

Preeclampsia/eclampsia (PE/E) contributes significantly to maternal, perinatal morbidity and mortality in Nigeria. The objectives of the study were to ascertain the prevalence, materno-fetal outcomes and sociodemographic factors associated with PE/E at Nigerian Teaching Hospital from September 2014 to August 2019.

Methods

This was a retrospective cross-sectional study that analyzed deidentified secondary data of women managed for PE/E at a teaching hospital in north-central, Nigeria. Descriptive statistics were used to determine sample characteristics and study outcome estimates. Bivariate analysis was used to test for associations between sociodemographic factors and PE/E, materno-fetal outcomes while logistic regression analysis was used to test for the magnitude of these associations. The significance level was set at P < 0.05.

Results

The prevalence of PE/E in this study was 3.60%. Preeclampsia was diagnosed in 3.02% of cases while eclampsia was the diagnosis in 0.58%. Case fatality rate was 3.9% and still birth rate was 10.7%. Majority of women (85.4%) did not have any maternal complication nor unfavorable outcome. Majority (67.7%), of babies weighed less than 2500 g and birth weight was the only sociodemographic factor that was significantly associated with fetal outcome (X² = 15.6, P < 0.001).

Conclusions

The prevalence of PE/E in this study is high and is associated with high maternal and perinatal deaths. Majority of the cases of PE/E as well the fatalities occurred in women who had no formal education, unbooked and referred to the teaching hospital with worsening conditions. There is need for explorative research on community factors associated with PE/E and its outcome towards prevention and early management of cases.

Women's perceptions and self-reports of excessive bleeding during and after delivery: findings from a mixed-methods study in Northern Nigeria

OBJECTIVES

To explore lay perceptions of bleeding during and after delivery, and measure the frequency of self-reported indicators of bleeding.

SETTING

Yola, North-East Nigeria.

PARTICIPANTS

Women aged 15-49 years who delivered in the preceding 2 years of data collection period (2015-2016), and their family members who played key roles.

METHODS

Data on perceptions of bleeding were collected through 7 focus group discussions, 21 in-depth interviews and 10 family interviews. Sampling was purposive and data were analysed thematically. A household survey was then conducted with 640 women using cluster sampling on postpartum bleeding indicators developed from the qualitative data; data were analysed descriptively.

RESULTS

Perceptions of excessive bleeding fell under four themes: quantity of blood lost; rate/duration of blood flow; symptoms related to blood loss and receiving birth interventions/hearing comments from birth attendants. Young and less educated rural women had difficulty quantifying blood loss objectively, including when shown quantities using bottles. Respondents felt that acceptable blood loss levels depended on the individual woman and whether the blood is 'good' or 'diseased/bad.' Respondents believed that 'diseased' blood was a normal result of delivery and universally took steps to help it 'come out.' In the quantitative survey, indicators representing less blood loss were reported more frequently than those representing greater loss, for example, more women reported staining their clothes (33.6%) than the bed (18.1%) and the floor (6.2%). Overall, indicators related to quantity and rate of blood flow had higher frequencies compared with symptom and intervention-related/comment-related indicators.

CONCLUSION

Women quantify bleeding during and after delivery in varied ways and some women do not see bleeding as problematic. This suggests the need for standard messaging to address subjectivity. The range of indicators and varied frequencies highlight the challenges of measuring excessive bleeding from self-reports. More work is needed in improving and testing validity of questions.

Maternal mortality: near-miss events in middle-income countries, a systematic review

OBJECTIVE

To describe the incidence and main causes of maternal near-miss events in middle-income countries using the World Health Organization's (WHO) maternal near-miss tool and to evaluate its applicability in these settings.

METHODS

We did a systematic review of studies on maternal near misses in middle-income countries published over 2009-2020. We extracted data on number of live births, number of maternal near misses, major causes of maternal near miss and most frequent organ dysfunction. We extracted, or calculated, the maternal near-miss ratio, maternal mortality ratio and mortality index. We also noted descriptions of researchers' experiences and modifications of the WHO tool for local use.

FINDINGS

We included 69 studies from 26 countries (12 lower-middle- and 14 upper-middle-income countries). Studies reported a total of 50 552 maternal near misses out of 10 450 482 live births. Median number of cases of maternal near miss per 1000 live births was 15.9 (interquartile range, IQR: 8.9-34.7) in lower-middle- and 7.8 (IQR: 5.0-9.6) in upper-middle-income countries, with considerable variation between and within countries. The most frequent causes of near miss were obstetric haemorrhage in 19/40 studies in lower-middle-income countries and hypertensive disorders in 15/29 studies in upper-middle-income countries. Around half the studies recommended adaptations to the laboratory and management criteria to avoid underestimation of cases of near miss, as well as clearer guidance to avoid different interpretations of the tool.

CONCLUSION

In several countries, adaptations of the WHO near-miss tool to the local context were suggested, possibly hampering international comparisons, but facilitating locally relevant audits to learn lessons.

Factors associated with severe maternal outcomes in patients with eclampsia in an obstetric intensive care unit: A cohort study

To describe the clinical profile, management, maternal outcomes and factors associated with severe maternal outcome (SMO) in patients admitted for eclampsia.A retrospective cohort study was carried out. All women admitted to the Obstetric Intensive Care Unit (ICU) at Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Northeast of Brazil, from April 2012 to December 2019 were considered for inclusion and patients with the diagnosis of eclampsia were selected. Patients who, after reviewing their medical records, did not present a diagnosis of eclampsia were excluded from the study. Severe maternal outcome (SMO) was defined as all cases of near miss maternal mortality (MNM) plus all maternal deaths during the study period. The Risk Ratio (RR) and its 95% confidence interval (95% CI) were calculated as a measure of the relative risk. Multiple logistic regression analysis was performed to control confounding variables. The institute's internal review board and the board waived the need of the informed consent.Among 284 patients with eclampsia admitted during the study period, 67 were classified as SMO (23.6%), 63 of whom had MNM (22.2%) and 5 died (1.8%). In the bivariate analysis, the following factors were associated with SMO: age 19 years or less (RR = 0.57 95% CI 0.37-0.89, P = .012), age 35 years or more (RR = 199 95% CI 1.18-3.34, P = .019), the presence of associated complications such as acute kidney injury (RR = 3.85 95% CI 2.69-5.51, P < .001), HELLP syndrome (RR = 1.81 95% CI 1.20-2.75, P = .005), puerperal hemorrhage (PPH) (RR = 2.15 95% CI 1.36-3.40, P = .003) and acute pulmonary edema (RR = 2.78 95% CI 1.55-4.96, P = .008). After hierarchical multiple logistic regression analysis, the factors that persisted associated with SMO were age less than or equal to 19 years (ORa = 0.46) and having had PPH (ORa = 3.33).Younger age was a protective factor for developing SMO, while those with PPH are more likely to have SMO.

Persistent Hypertension Up to One Year Postpartum among Women with Hypertensive Disorders in Pregnancy in a Low-Resource Setting: A Prospective Cohort Study

Background

Hypertensive disorders in pregnancy (HDPs) are associated with lifelong cardiovascular disease risk. Persistent postpartum hypertension in HDPs could suggest progression to chronic hypertension. This phenomenon has not been well examined in low- and middle-income countries (LIMCs), and most previous follow-ups typically last for maximally six weeks postpartum. We assessed the prevalence of persistent hypertension up to one year in women with HDPs in a low resource setting and determined associated risk factors.

Methodology

A prospective cohort study of women conducted at eight tertiary health care facilities in seven states of Nigeria. Four hundred and ten women with any HDP were enrolled within 24 hours of delivery and followed up at intervals until one year postpartum. Descriptive statistics were performed to express the participants' characteristics. Univariable and multivariable logistic regressions were conducted to identify associated risk factors.

Results

Of the 410 women enrolled, 278 were followed up to one year after delivery (follow-up rate 68%). Among women diagnosed with gestational hypertension and pre-eclampsia/eclampsia, 22.3% (95% CI; 8.3-36.3) and 62.1% (95% CI; 52.5-71.9), respectively, had persistent hypertension at six months and this remained similar at one year 22.3% (95% CI; 5.6-54.4) and 61.2% (95% CI; 40.6-77.8). Maternal age and body mass index were significant risk factors for persistent hypertension at one year [aORs = 1.07/year (95% CI; 1.02-1.13) and 1.06/kg/m2 (95% CI; 1.01-1.10)], respectively.

Conclusion

This study showed a substantial prevalence of persistent hypertension beyond puerperium. Health systems in LMICs need to be organized to anticipate and maintain postpartum monitoring until blood pressure is normalized, or women referred or discharged to family physicians as appropriate. In particular, attention should be given to women who are obese, and or of higher maternal age.

Determinants of the decision-to-delivery interval and the effect on perinatal outcome after emergency caesarean delivery: a cross-sectional study

Background

Preventing prolongation of the decision-to-delivery interval (DDI) for emergency caesarean delivery (CD) remains central to improving perinatal health. This study evaluated the effects of the DDI on perinatal outcome following emergency CD.

Methods

A prospective cross-sectional study involving 205 consenting women who had emergency CD at a tertiary hospital in Nigeria was conducted. The time-motion documentation of events from decision to delivery was documented; the outcome measures were perinatal morbidity (neonatal resuscitation, 5-minute Apgar score, neonatal intensive admission) and mortality. Data analysis was performed with IBM SPSS Statistics version 20.0, and P<0.05 was considered significant.

Results

The overall mean DDI was 233.99±132.61 minutes (range 44–725 minutes); the mean DDI was shortest for cord prolapse (86.25±86.25 minutes) and was shorter for booked participants compared with unbooked participants (207.19±13.88 minutes vs 249.25±12.05 minutes; P=0.030) and for general anaesthesia compared with spinal anaesthesia (219.48±128.60 minutes vs 236.19±133.42 minutes; P=0.543). All neonatal parameters were significantly worse for unbooked women compared with booked women, including perinatal mortality (10.8% vs 1.3%; P=0.012). Neonatal morbidity increased with DDI for clinical indications, UK National Institute of Health and Care Excellence (NICE) and Robson classification for CDs; perinatal mortality was 73.2 per 1000 live births, all were category 1 CDs and all except one occurred with DDI greater than 90 minutes. Severe preeclampsia/eclampsia, obstructed labour and placenta praevia tolerated DDI greater than 90 minutes compared with abruptio placentae and umbilical cord prolapse. However, logistic regression showed no statistical correlation between the DDI and neonatal outcomes.

Conclusion

Perinatal morbidity and mortality increased with DDI relative to the clinical urgency but perinatal deaths were increased with DDI greater than 90 minutes. For no category of emergency CD should the DDI exceed 90 minutes, while patient and institutional factors should be addressed to reduce the DDI.

Maternal Death Review at a Tertiary Hospital in Ethiopia

Background

There is conflicting data on the rate and trends of maternal mortality in Ethiopia. There is no previous study done on the magnitude and trends of maternal death at Saint Paul's Hospital, an institution providing the largest labor and delivery services in Ethiopia. The objective of this study is to determine the magnitude, causes and contributing factors for maternal deaths in the institution.

Methods

We conducted a retrospective review of maternal deaths from January 2016 to December 2017. Data were analyzed using SPSS version 20.

Results

The maternal mortality ratio of the institution was 228.3 per 100,000 live births. Direct maternal death accounted for 90% (n=36) of the deceased. The leading causes of the direct maternal deaths were hypertensive disorders of pregnancy (n=13, 32.5%), postpartum hemorrhage (n=10, 25%), sepsis (n=4, 10%), pulmonary thromboembolism (n=3, 7.5%) and amniotic fluid embolism (n=3, 7.5%).

Conclusion

The maternal mortality ratio was lower than the ratios reported from other institutions in Ethiopia. Hypertensive disorders of pregnancy and malaria were the leading cause of direct and indirect causes of maternal deaths respectively. Embolism has become one of the top causes of maternal death in a rate like the developed nations. This might show the double burden of embolism and other causes of maternal mortality that developing countries might be facing.

Falling through the net: An adaptive assessment of the 'Three Delays' encountered by patients seeking emergency maternal and neonatal care within a remote health system on Lake Victoria, Kenya

In rural sub-Saharan Africa, preventable delays in accessing emergency care remain a dominant factor in maternal and neonatal deaths. The MOMENTUM study is a pragmatic cohort investigation designed to measure the "Three Delays", i.e. delays in recognizing need for care (Type 1), reaching care (Type 2), and receiving care (Type 3) within a remote island health system on Lake Victoria, Kenya. The study utilizes an adaptive methodology to provide actionable data for a locally-directed "Health Navigation" intervention. We present analysis of 56 maternal and neonatal emergency cases occurring between January 2019 and February 2020. The mean Total Delay Interval (Type 1-3) reported was 39.3 ± 32.3hours. Notably, 18 cases in this cohort resulted in a neonatal (n = 16) or maternal death (n = 2). Sub-analysis indicates significant delay interval reductions associated with involvement of a "Health Navigator" in emergency care coordination for Type 2 Delay Intervals (0.5 ± 0.3 vs. 1.2 ±  1.1 hrs., p = 0.002) and Type 3 Delay Intervals (17.9 ± 14.1 vs. 32.9 ± 33.7 hrs., p = 0.030). Prolonged delays, complex barriers, and high mortality highlight the fraught nature of maternal emergencies in this remote setting. We discuss practical considerations for application of the Three Delays model, and avenues for further investigation.

Adherence to Guidelines in Postpartum Management of Hypertensive Disorders in Pregnancy in Tertiary Health Facilities in Nigeria: A Multi-centre Study

Hypertensive disorders in pregnancy (HDPs) are a leading cause of maternal morbidity and mortality. Available guidelines for their postpartum management are expected to be optimally utilized. This study aimed to determine adherence to guidelines in selected Nigerian tertiary hospitals. It was nested in a cohort of women with HDPs who delivered in eight facilities between October 2017 and June 2018. Nine weeks after delivery, their cases were evaluated on prespecified indicators and supplemented with interviews. The level of adherence to the guidelines was determined using descriptive analyses, including frequencies, percentages, means, and standard deviations, as well as charts. Of the 366 participants, 33 (9%), 75 (20%), 200 (55%), and 58 (16%) had chronic hypertension, gestational hypertension, preeclampsia, and eclampsia, respectively. Only about a third had their blood pressure measured between postpartum days three and five. Similarly, a third of those with persistent hypertension (≥140/90 mmHg) were not on antihypertensive medications within the first week postpartum. In addition, 37% and 42% of participants were not counseled on contraceptives and early subsequent antenatal visits, respectively. Among those with preeclampsia/eclampsia, 93% were not offered postpartum screening for thromboprophylaxis. Although all women with preeclampsia/eclampsia remained hypertensive two weeks after discharge, only 24% had medical reviews. Overall, only 58% and 44% of indicators were adhered to among all HDPs and preeclampsia/eclampsia-specific indicators, respectively. Level of adherence to guidelines on postpartum management of HDPs in Nigerian tertiary hospitals is poor. It is recommended that institutionalization of guidelines be prioritized and linked to the entire continuum from preconception through longer term postpartum care.

"In cities, it's not far, but it takes long": comparing estimated and replicated travel times to reach life-saving obstetric care in Lagos, Nigeria

BACKGROUND

Travel time to comprehensive emergency obstetric care (CEmOC) facilities in low-resource settings is commonly estimated using modelling approaches. Our objective was to derive and compare estimates of travel time to reach CEmOC in an African megacity using models and web-based platforms against actual replication of travel.

METHODS

We extracted data from patient files of all 732 pregnant women who presented in emergency in the four publicly owned tertiary CEmOC facilities in Lagos, Nigeria, between August 2018 and August 2019. For a systematically selected subsample of 385, we estimated travel time from their homes to the facility using the cost-friction surface approach, Open Source Routing Machine (OSRM) and Google Maps, and compared them to travel time by two independent drivers replicating women's journeys. We estimated the percentage of women who reached the facilities within 60 and 120 min.

RESULTS

The median travel time for 385 women from the cost-friction surface approach, OSRM and Google Maps was 5, 11 and 40 min, respectively. The median actual drive time was 50-52 min. The mean errors were >45 min for the cost-friction surface approach and OSRM, and 14 min for Google Maps. The smallest differences between replicated and estimated travel times were seen for night-time journeys at weekends; largest errors were found for night-time journeys at weekdays and journeys above 120 min. Modelled estimates indicated that all participants were within 60 min of the destination CEmOC facility, yet journey replication showed that only 57% were, and 92% were within 120 min.

CONCLUSIONS

Existing modelling methods underestimate actual travel time in low-resource megacities. Significant gaps in geographical access to life-saving health services like CEmOC must be urgently addressed, including in urban areas. Leveraging tools that generate 'closer-to-reality' estimates will be vital for service planning if universal health coverage targets are to be realised by 2030.

Lack of experience is a main cause of maternal death in placenta accreta spectrum patients

INTRODUCTION

Placenta accreta spectrum (PAS) is a serious condition with a mortality as high as 7%. However, the factors associated with this type of death have not been adequately described, with an almost total lack of publications analyzing the determining factors of death in this disease. The aim of our work is to describe the causes of death related to PAS and to analyze the associated diagnosis and treatment problems.

MATERIAL AND METHODS

This is an inter-continental, multicenter, descriptive, retrospective study in low- and middle-income countries. Maternal deaths related to PAS between January 2015 and December 2020 were included. Crucial points in the management of PAS, including prenatal diagnosis and details of the surgical treatment and postoperative management, were evaluated.

RESULTS

Eighty-two maternal deaths in 16 low- and middle-income countries, on three continents, were included. Almost all maternal deaths (81 cases, 98.8%) were preventable, with inexperience among surgeons being identified as the most relevant problem in the process that led to death among 87% (67 women) of the cases who had contact with health services. The main cause of death associated with PAS was hemorrhage (69 cases, 84.1%), and failures in the process leading to the diagnosis were detected among 64.6% of cases. Although the majority of cases received medical attention and 50 (60.9%) were treated at referral centers for severe obstetric disease, problems were identified during treatment in all cases.

CONCLUSIONS

Lack of experience and inadequate surgical technique are the most frequent problems associated with maternal deaths in PAS. Continuous training of interdisciplinary teams is critical to modify this tendency.

Supply, Demand, and Quality: A Three-Pronged Approach to Blood Product Management in Developing Countries

While transfusion of blood and blood products is instinctively linked to the provision of emergent care, blood and blood products are also routinely used for the treatment of subacute and chronic conditions. Despite the efforts of the World Health Organization and others, developing countries are faced with a three-part problem when it comes to access to and delivery of transfusions: insufficient supply, excessive demand, and inadequate quality of available supply. Developing countries rely heavily on replacement and remunerated donors rather than voluntary nonremunerated donors due to concerns regarding donation- and transfusion-transmitted infection as well as local and cultural beliefs. While increased awareness of HIV and improved testing techniques have jointly reduced infection-related apprehensions and improved the quality of available blood and blood products, continued efforts are warranted to bolster testing for other bloodborne pathogens. Similarly, although prevalence rates of anemia are high in some areas of the world, success in adequate widespread management of these conditions has been limited. One of the keys to expanding access to high-quality blood and blood products is thus to improve medical management of conditions that would otherwise require transfusion. Through a three-pronged approach to address quantity, quality, and demand, developing countries can enable themselves to build toward self-sufficient blood management services and increased independence from the support of international organizations.

Maternal near miss among women admitted in major private hospitals in eastern Ethiopia: a retrospective study

BACKGROUND

Since maternal mortality is a rare event, maternal near miss has been used as a proxy indicator for measuring maternal health. Maternal near miss (MNM) refers to a woman who nearly died but survived of complications during pregnancy, childbirth or within 42 days of termination of pregnancy. Although study of MNM in Ethiopia is becoming common, it is limited to public facilities leaving private facilities aside. The objective of this study was to assess MNM among women admitted in major private hospitals in eastern Ethiopia.

METHODS

An institution based retrospective study was conducted from March 05 to 31, 2020 in two major private hospitals in Harar and Dire Dawa, eastern Ethiopia. The records of all women who were admitted during pregnancy, delivery or within 42 days of termination of pregnancy was reviewed for the presence of MNM criteria as per the sub-Saharan African MNM criteria. Descriptive analysis was done by computing proportion, ratio and means. Factors associated with MNM were assessed using binary logistic regression with adjusted odds ratio (aOR) along with its 95% confidence interval (CI).

RESULTS

Of 1214 pregnant or postpartum women receiving care between January 09, 2019 and February 08, 2020, 111 women developed life-threatening conditions: 108 MNM and 3 maternal deaths. In the same period, 1173 live births were registered, resulting in an MNM ratio of 92.1 per 1000 live births. Anemia in the index pregnancy (aOR: 5.03; 95%CI: 3.12-8.13), having chronic hypertension (aOR: 3.13; 95% CI: 1.57-6.26), no antenatal care (aOR: 3.04; 95% CI: 1.58-5.83), being > 35 years old (aOR: 2.29; 95%CI: 1.22-4.29), and previous cesarean section (aOR: 4.48; 95% CI: 2.67-7.53) were significantly associated with MNM.

CONCLUSIONS

Close to a tenth of women admitted to major private hospitals in eastern Ethiopia developed MNM. Women with anemia, history of cesarean section, and old age should be prioritized for preventing and managing MNM. Strengthening antenatal care and early screening of chronic conditions including hypertension is essential for preventing MNM.

Maternal Near Miss: Unraveling Our Experience in the Tertiary Care Hospital of Andaman and Nicobar Islands

Context

Women who survive life-threatening complications related to pregnancy and delivery have many common aspects with those who die of such complications. This similarity brought forward the near miss concept in maternal health. Analysis of the similarities, differences, and the relationship between these two groups of women provide a complete assessment of quality of maternal health care.

Aims

The aim of this study is to assess the baseline indices of maternal near miss (MNM) and analyze the quality of care at a tertiary care center in Andaman and Nicobar Islands.

Settings and Design

Facility-based, cross-sectional study.

Subjects and Methods

The study was conducted for a period of 18 months from January 1, 2015, to August 31, 2016. Cases, who met the World Health Organization (WHO) criteria of severe obstetric morbidity, were included and followed up during their hospital stay and till their discharge or death. Quality of maternal health care was assessed through the WHO near-miss criteria and criterion-based clinical audit methodology.

Statistical Analysis Used

Descriptive statistics using mean and percentages and Student's t-test were used.

Results

Among 4720 women who delivered in our hospital, there were 4677 live births, 52 patients were near miss, and there were 9 maternal deaths. The MNM incidence ratio was 11.11%, the MNM mortality ratio was 5.77, and the mortality index 14.75%. The most common cause of maternal morbidity was hemorrhage followed by hypertensive disorders.

Conclusions

Improving referral systems, effective use of critical care, and evidence-based interventions can potentially reduce severe maternal outcomes.

Preoperative vaginal cleansing with chlorhexidine solution in preventing post-cesarean section infections in a low resource setting: A randomized controlled trial

INTRODUCTION

Infection is one of the most common causes of maternal morbidities and mortality and has been reported to be responsible for about 15% of maternal deaths. Any woman is at risk of infection during childbirth, but women undergoing cesarean section are at higher risk. Improvement in surgical procedures with asepsis and the use of antibiotics have helped reduce postoperative infectious morbidities. However, ascending infection from the lower to the upper genital tract is a common but often neglected source of infection. Cleaning the vagina with chlorhexidine antiseptic solution before cesarean section can be a cheap and affordable source of infection control. This study is aimed at evaluating the efficacy of preoperative vaginal cleansing using 1.0% chlorhexidine in the reduction of post-cesarean section infectious morbidities.

MATERIAL AND METHODS

This prospective randomized control trial was conducted among 322 pregnant women who underwent an emergency cesarean section at Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AE-FUTHA). The women were randomized into two groups. The interventional group received vaginal cleansing with three standard gauzes soaked in 30 mL 1.0% chlorhexidine gluconate solution preoperatively in addition to surgical skin cleaning with chlorhexidine-alcohol. The women in the control group only had surgical skin cleaning with chlorhexidine-alcohol. All the women received pre- and postoperative antibiotics. The primary outcomes were endometritis and wound infections.

RESULTS

Infectious morbidity was significantly reduced from 36.8% in the control group to 12.0% in the intervention group (P = .001). Endometritis occurred significantly less frequently in the intervention group than the control group (respectively 6.6% compared with 27.6%: relative risk [RR] 0.29, 95% confidence interval [CI] 0.16-0.53; P < .05). Foul-smelling vaginal discharge was significantly more common in the control group than in the intervention group (11.8% vs 1.3%, respectively) but the CI was wide (RR 8.5, 95% CI 1.30-64.55; P < .001). Fever and wound infection were more common in the control group (5.9% vs 3.3% and 9.2% vs 5.3%) but the difference was not significant. The hospital stay was significantly shorter among the intervention group (5.54 ± 1.04 days compared with 6.01 ± 1.55 days, P < 0.05). The most common microbial isolate implicated in endocervical colonization was Staphylococcus aureus followed by Klebsiella species.

CONCLUSIONS

Vaginal cleansing with 1.0% chlorhexidine gluconate solution before emergency cesarean section appears to be effective in reducing rates of post-cesarean section infectious morbidity in the study area. We recommend its use among women undergoing cesarean section to help reduce the contribution of infections to a poor obstetrics outcome.

Resilience to maintain quality of intrapartum care in war torn Yemen: a retrospective pre-post study evaluating effects of changing birth volumes in a congested frontline hospital

BACKGROUND

Fragile and conflict-affected states contribute with more than 60% of the global burden of maternal mortality. There is an alarming need for research exploring maternal health service access and quality and adaptive responses during armed conflict. Taiz Houbane Maternal and Child Health Hospital in Yemen was established during the war as such adaptive response. However, as number of births vastly exceeded the facility's pre-dimensioned capacity, a policy was implemented to restrict admissions. We here assess the restriction's effects on the quality of intrapartum care and birth outcomes.

METHODS

A retrospective before and after study was conducted of all women giving birth in a high-volume month pre-restriction (August 2017; n = 1034) and a low-volume month post-restriction (November 2017; n = 436). Birth outcomes were assessed for all births (mode of birth, stillbirths, intra-facility neonatal deaths, and Apgar score < 7). Quality of intrapartum care was assessed by a criterion-based audit of all caesarean sections (n = 108 and n = 82) and of 250 randomly selected vaginal births in each month.

RESULTS

Background characteristics of women were comparable between the months. Rates of labour inductions and caesarean sections increased significantly in the low-volume month (14% vs. 22% (relative risk (RR) 0.62, 95% confidence interval (CI) 0.45-0.87) and 11% vs. 19% (RR 0.55, 95% CI 0.42-0.71)). No other care or birth outcome indicators were significantly different. Structural and human resources remained constant throughout, despite differences in patient volume.

CONCLUSIONS

Assumptions regarding quality of care in periods of high demand may be misguiding - resilience to maintain quality of care was strong. We recommend health actors to closely monitor changes in quality of care when implementing resource changes; to enable safe care during birth for as many women as possible.

Applying the WHO ICD-MM classification system to maternal deaths in a tertiary hospital in Nigeria: A retrospective analysis from 2014-2018

BACKGROUND

Addressing the problem of maternal mortality in Nigeria requires proper identification of maternal deaths and their underlying causes in order to focus evidence-based interventions to decrease mortality and avert morbidity.

OBJECTIVES

The objective of the study was to classify maternal deaths that occurred at a Nigerian teaching hospital using the WHO International Classification of Diseases Maternal mortality (ICD-MM) tool.

METHODS

This was a retrospective observational study of all maternal deaths that occurred in a tertiary Nigerian hospital from 1st January 2014 to 31st December,2018. The WHO ICD-MM classification system for maternal deaths was used to classify the type, group, and specific underlying cause of identified maternal deaths. Descriptive analysis was performed using Statistical Package for Social Sciences (SPSS). Categorical and continuous variables were summarized respectively as proportions and means (standard deviations).

RESULTS

The institutional maternal mortality ratio was 831/100,000 live births. Maternal deaths occurred mainly amongst women aged 25-34 years;30(57.7%), without formal education; 22(42.3%), married;47(90.4%), unbooked;24(46.2%) and have delivered at least twice;34(65.4%). The leading causes of maternal death were hypertensive disorders in pregnancy, childbirth, and the puerperium (36.5%), obstetric haemorrhage (30.8%), and pregnancy related infections (17.3%). Application of the WHO ICD-MM resulted in reclassification of underlying cause for 3.8% of maternal deaths. Postpartum renal failure (25.0%), postpartum coagulation defects (17.3%) and puerperal sepsis (15.4%) were the leading final causes of death. Among maternal deaths, type 1, 2, and 3 delays were seen in 30(66.7%), 22(48.9%), and 6(13.3%), respectively.

CONCLUSION

Our institutional maternal mortality ratio remains high. Hypertensive disorders during pregnancy, childbirth, and the puerperium and obstetric haemorrhage are the leading causes of maternal deaths. Implementation of evidence-based interventions both at the hospital and community levels may help in tackling the identified underlying causes of maternal mortality in Nigeria.

Analysis of the Severe Maternal Outcomes between Resource-Poor and Resource-Rich Hospitals in China’s Hunan Province from 2012 to 2018

Background. This facility-based study analyzed the epidemiology and incidence of maternal near miss (MNM) and mortality by hospital level as part of Hunan Province’s efforts to raise the quality of hospital care for women. Methods. We used data for MNM and mortality cases for 2012–2018 from 17 hospitals (12 resource-poor facilities, five resource-rich facilities) that receive referrals for obstetric complications in Hunan Province. Data were drawn from China’s National Maternal Near Miss Surveillance System and collected using the World Health Organization near miss tool. We calculated the ratio of severe maternal outcomes (SMO) (i.e., MNM and maternal death (MD) cases), mortality index (MI), and MNM to mortality ratio (MNM : MD), and epidemiological factors, organ dysfunction, and maternal complications stratified by hospital level. The chi-square tests to examine differences between groups and total ratios and 95% CI were calculated. Results. There were 518 SMO cases (489 MNM and 29 MD) among 279407 live births (LBs) and 1299 SMO cases (1262 MNM and 37 MD) among 232386 LBs in resource-poor and resource-rich facilities. The total MNM ratio in resource-poor and resource-rich hospitals was 1.75 (95% CI: 1.60–1.91) and 5.43 (95% CI: 5.14–5.74) per 1000 LBs, respectively. There were differences in SMO cases between resource-poor and resource-rich hospitals in maternal age, education, parity, antenatal visits, and history of cesarean sections. In MNM cases, coagulation dysfunction was the main organ dysfunction (resource-poor hospitals: 59.10%; resource-rich hospitals: 79.32%), and the main maternal complications were obstetric hemorrhage (resource-poor hospitals: 71.98%) and hepatopathy (resource-rich hospitals: 69.49%). For MD cases, the main maternal complications were neurologic dysfunction (resource-poor hospitals: 41.38%) and coagulation dysfunction (resource-rich hospitals: 42.55%). Anemia was the main maternal complication for SMO cases in both resource-poor (69.69%) and resource-rich (68.59%) hospitals. Conclusions. MNM and MD are higher in resource-rich hospitals compared with resource-poor hospitals. The obstetric emergency capacity of resource-rich hospitals is higher than that of resource-poor hospitals. Future government policies should consider upgrading the obstetric emergency treatment capacity in resource-poor hospitals or to redistinguish the social functions of different medical institutions.

Intravenous versus intramuscular prophylactic oxytocin for the third stage of labour

BACKGROUND

There is general agreement that oxytocin given either through the intravenous or intramuscular route is effective in reducing postpartum blood loss. However, it is unclear whether the subtle differences between the mode of action of these routes have any effect on maternal and infant outcomes. This review was first published in 2012 and last updated in 2018.

OBJECTIVES

To determine the comparative effectiveness and safety of oxytocin administered intravenously or intramuscularly for prophylactic management of the third stage of labour after vaginal birth.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (19 December 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

Eligible studies were randomised trials comparing intravenous with intramuscular oxytocin for prophylactic management of the third stage of labour after vaginal birth. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence with the GRADE approach.

MAIN RESULTS

Seven trials, involving 7817 women, met the inclusion criteria for this review. The trials compared intravenous versus intramuscular administration of oxytocin just after the birth of the anterior shoulder or soon after the birth of the baby. All trials were conducted in hospital settings and included women with term pregnancies, undergoing a vaginal birth. Overall, the included studies were at moderate or low risk of bias, with two trials providing clear information on allocation concealment and blinding. For GRADE outcomes, the certainty of the evidence was generally moderate to high, except from two cases where the certainty of the evidence was either low or very low. High-certainty evidence suggests that intravenous administration of oxytocin in the third stage of labour compared with intramuscular administration carries a lower risk for postpartum haemorrhage (PPH) ≥ 500 mL (average risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92; six trials; 7731 women) and blood transfusion (average RR 0.44, 95% CI 0.26 to 0.77; four trials; 6684 women). Intravenous administration of oxytocin probably reduces the risk of PPH ≥ 1000 mL, although the 95% CI crosses the line of no-effect (average RR 0.65, 95% CI 0.39 to 1.08; four trials; 6681 women; moderate-certainty evidence). In all studies but one, there was a reduction in the risk of PPH ≥ 1000 mL with intravenous oxytocin. The study that found a large increase with intravenous administration was small (256 women), and contributed only 3% of total events. Once this small study was removed from the meta-analysis, heterogeneity was eliminated and the treatment effect favoured intravenous oxytocin (average RR 0.61, 95% CI 0.42 to 0.88; three trials; 6425 women; high-certainty evidence). Additionally, a sensitivity analysis, exploring the effect of risk of bias by restricting analysis to those studies rated as 'low risk of bias' for random sequence generation and allocation concealment, found that the prophylactic administration of intravenous oxytocin reduces the risk for PPH ≥ 1000 mL, compared with intramuscular oxytocin (average RR 0.64, 95% CI 0.43 to 0.94; two trials; 1512 women). The two routes of oxytocin administration may be comparable in terms of additional uterotonic use (average RR 0.78, 95% CI 0.49 to 1.25; six trials; 7327 women; low-certainty evidence). Although intravenous compared with intramuscular administration of oxytocin probably results in a lower risk for serious maternal morbidity (e.g. hysterectomy, organ failure, coma, intensive care unit admissions), the confidence interval suggests a substantial reduction, but also touches the line of no-effect. This suggests that there may be no reduction in serious maternal morbidity (average RR 0.47, 95% CI 0.22 to 1.00; four trials; 7028 women; moderate-certainty evidence). Most events occurred in one study from Ireland reporting high dependency unit admissions, whereas in the remaining three studies there was only one case of uvular oedema. There were no maternal deaths reported in any of the included studies (very low-certainty evidence). There is probably little or no difference in the risk of hypotension between intravenous and intramuscular administration of oxytocin (RR 1.01, 95% CI 0.88 to 1.15; four trials; 6468 women; moderate-certainty evidence). Subgroup analyses based on the mode of administration of intravenous oxytocin (bolus injection or infusion) versus intramuscular oxytocin did not show any substantial differences on the primary outcomes. Similarly, additional subgroup analyses based on whether oxytocin was used alone or as part of active management of the third stage of labour (AMTSL) did not show any substantial differences between the two routes of administration.

AUTHORS' CONCLUSIONS

Intravenous administration of oxytocin is more effective than its intramuscular administration in preventing PPH during vaginal birth. Intravenous oxytocin administration presents no additional safety concerns and has a comparable side effects profile with its intramuscular administration. Future studies should consider the acceptability, feasibility and resource use for the intervention, especially in low-resource settings.

Epigenetic Modification in Methylene Tetrahydrofolate Reductase (MTHFR) Gene of Women with Pre-eclampsia

Background

Genetic and epigenetic factors play significant roles in the aetio-pathogenesis of pre-eclampsia (PE). The effects may vary across racial and geographical boundaries. The role of epigenetic modification in pre-eclampsia was studied among African populations in Lagos, Nigeria.

Aim and Objectives

This study aimed to determine the pattern of Methylene tetrahydrofolate reductase gene (MTHFR) CpG island methylation in pre-eclampsia, and evaluate associated covariates.

Methodology

This study was an observational, cross-sectional, study conducted at the Lagos University Teaching Hospital and the Lagos State Island Maternity Hospital. A total of 400 pregnant women consisting of 200 pregnant women diagnosed with pre-eclampsia (study group) and 200 pregnant normotensive and apparently healthy women (control group) were recruited for the study. Demographic and clinical histories were obtained through questionnaires. The DNA Methylation status of the CpG Island in promoter region of the MTHFR gene was assessed using bisulphite conversion and methylation specific PCR method. The biochemical parameters measured in the study were: red cell folate, vitamin B12, plasma homocysteine (Hcy) and methylene tetrahydrofolate reductase enzyme level.

Results

Homozygous MTHFR CpG island hypomethylation pattern was significantly associated with pre-eclampsia (χ ² = 22.96; p = 0.000), Mean values of plasma homocysteine in PE women with homozygous hypomethylation (26.1 ± 9.1 umol/L) were significantly higher than (20.1 ± 4.2 umol/L) observed in PE subjects with homozygous hypermethylation (p = 0.008). Homozygous CpG island hypomethylated pattern of the MTHFR promoter region, was associated with the lowest median MTHFR enzyme level (72.8 ± 39.8 pmol/L) compared with heterozygous methylated pattern (91.3 ± 60.9 pmol/L; p = 0.047) and homozygous methylated pattern (82.3 ± 31.0 pmol/L; 0.047). Red cell folate and Vitamin B12 levels were not significantly associated with CpG island methylation status.

Conclusion

Epigenetic modification plays significant role in the pathogenesis of pre-eclampsia.

Incidence of maternal near-miss in Kenya in 2018: findings from a nationally representative cross-sectional study in 54 referral hospitals

Although the Kenyan government has made efforts to invest in maternal health over the past 15 years, there is no evidence of decline in maternal mortality. To provide necessary evidence to inform maternal health care provision, we conducted a nationally representative study to describe the incidence and causes of maternal near-miss (MNM), and the quality of obstetric care in referral hospitals in Kenya. We collected data from 54 referral hospitals in 27 counties. Individuals admitted with potentially life-threatening conditions (using World Health Organization criteria) in pregnancy, childbirth or puerperium over a three month study period were eligible for inclusion in our study. All cases of severe maternal outcome (SMO, MNM cases and deaths) were prospectively identified, and after consent, included in the study. The national annual incidence of MNM was 7.2 per 1,000 live births and the intra-hospital maternal mortality ratio was 36.2 per 100,000 live births. The major causes of SMOs were postpartum haemorrhage and severe pre-eclampsia/eclampsia. However, only 77% of women with severe preeclampsia/eclampsia received magnesium sulphate and 67% with antepartum haemorrhage who needed blood received it. To reduce the burden of SMOs in Kenya, there is need for timely management of complications and improved access to essential emergency obstetric care interventions.

Development and validation of an obstetric early warning system model for use in low resource settings

BACKGROUND

The use of obstetric early-warning-systems (EWS) has been recommended to improve timely recognition, management and early referral of women who have or are developing a critical illness. Development of such prediction models should involve a statistical combination of predictor clinical observations into a multivariable model which should be validated. No obstetric EWS has been developed and validated for low resource settings. We report on the development and validation of a simple prediction model for obstetric morbidity and mortality in resource-limited settings.

METHODS

We performed a multivariate logistic regression analysis using a retrospective case-control analysis of secondary data with clinical indices predictive of severe maternal outcome (SMO). Cases for design and validation were randomly selected (n = 500) from 4360 women diagnosed with SMO in 42 Nigerian tertiary-hospitals between June 2012 and mid-August 2013. Controls were 1000 obstetric admissions without SMO diagnosis. We used clinical observations collected within 24 h of SMO occurrence for cases, and normal births for controls. We created a combined dataset with two controls per case, split randomly into development (n = 600) and validation (n = 900) datasets. We assessed the model's validity using sensitivity and specificity measures and its overall performance in predicting SMO using receiver operator characteristic (ROC) curves. We then fitted the final developmental model on the validation dataset and assessed its performance. Using the reference range proposed in the United Kingdom Confidential-Enquiry-into-Maternal-and-Child-Health 2007-report, we converted the model into a simple score-based obstetric EWS algorithm.

RESULTS

The final developmental model comprised abnormal systolic blood pressure-(SBP > 140 mmHg or < 90 mmHg), high diastolic blood pressure-(DBP > 90 mmHg), respiratory rate-(RR > 40/min), temperature-(> 38 °C), pulse rate-(PR > 120/min), caesarean-birth, and the number of previous caesarean-births. The model was 86% (95% CI 81-90) sensitive and 92%- (95% CI 89-94) specific in predicting SMO with area under ROC of 92% (95% CI 90-95%). All parameters were significant in the validation model except DBP. The model maintained good discriminatory power in the validation (n = 900) dataset (AUC 92, 95% CI 88-94%) and had good screening characteristics. Low urine output (300mls/24 h) and conscious level (prolonged unconsciousness-GCS < 8/15) were strong predictors of SMO in the univariate analysis.

CONCLUSION

We developed and validated statistical models that performed well in predicting SMO using data from a low resource settings. Based on these, we proposed a simple score based obstetric EWS algorithm with RR, temperature, systolic BP, pulse rate, consciousness level, urinary output and mode of birth that has a potential for clinical use in low-resource settings..

Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study

Background

Maternal infections are an important cause of maternal mortality and severe maternal morbidity. We report the main findings of the WHO Global Maternal Sepsis Study, which aimed to assess the frequency of maternal infections in health facilities, according to maternal characteristics and outcomes, and coverage of core practices for early identification and management.

Methods

We did a facility-based, prospective, 1-week inception cohort study in 713 health facilities providing obstetric, midwifery, or abortion care, or where women could be admitted because of complications of pregnancy, childbirth, post-partum, or post-abortion, in 52 low-income and middle-income countries (LMICs) and high-income countries (HICs). We obtained data from hospital records for all pregnant or recently pregnant women hospitalised with suspected or confirmed infection. We calculated ratios of infection and infection-related severe maternal outcomes (ie, death or near-miss) per 1000 livebirths and the proportion of intrahospital fatalities across country income groups, as well as the distribution of demographic, obstetric, clinical characteristics and outcomes, and coverage of a set of core practices for identification and management across infection severity groups.

Findings

Between Nov 28, 2017, and Dec 4, 2017, of 2965 women assessed for eligibility, 2850 pregnant or recently pregnant women with suspected or confirmed infection were included. 70·4 (95% CI 67·7–73·1) hospitalised women per 1000 livebirths had a maternal infection, and 10·9 (9·8–12·0) women per 1000 livebirths presented with infection-related (underlying or contributing cause) severe maternal outcomes. Highest ratios were observed in LMICs and the lowest in HICs. The proportion of intrahospital fatalities was 6·8% among women with severe maternal outcomes, with the highest proportion in low-income countries. Infection-related maternal deaths represented more than half of the intrahospital deaths. Around two-thirds (63·9%, n=1821) of the women had a complete set of vital signs recorded, or received antimicrobials the day of suspicion or diagnosis of the infection (70·2%, n=1875), without marked differences across severity groups.

Interpretation

The frequency of maternal infections requiring management in health facilities is high. Our results suggest that contribution of direct (obstetric) and indirect (non-obstetric) infections to overall maternal deaths is greater than previously thought. Improvement of early identification is urgently needed, as well as prompt management of women with infections in health facilities by implementing effective evidence-based practices.

Funding

UNDP–UNFPA–UNICEF–WHO–World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and United States Agency for International Development.