Substandard emergency obstetric care - a confidential enquiry into maternal deaths at a regional hospital in Tanzania

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis

BACKGROUND

Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries.

OBJECTIVES

Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings.

SEARCH METHODS

We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers.

DATA COLLECTION AND ANALYSIS

We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice.

MAIN RESULTS

We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence).

AUTHORS' CONCLUSIONS

Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.

Causes for Medical Errors in Obstetrics and Gynaecology

Background: Quality strategies, interventions, and frameworks have been developed to facilitate a better understanding of healthcare systems. Reporting adverse events is one of these strategies. Gynaecology and obstetrics are one of the specialties with many adverse events. To understand the main causes of medical errors in gynaecology and obstetrics and how they could be prevented, we conducted this systematic review. Methods: This systematic review was performed in compliance with the Prisma 2020 guidelines. We searched several databases for relevant studies (Jan 2010-May 2023). Studies were included if they indicated the presence of any potential risk factor at the hospital level for medical errors or adverse events in gynaecology or obstetrics. Results: We included 26 articles in the quantitative analysis of this review. Most of these (n = 12) are cross-sectional studies; eight are case-control studies, and six are cohort studies. One of the most frequently reported contributing factors is delay in healthcare. In addition, the availability of products and trained staff, team training, and communication are often reported to contribute to near-misses/maternal deaths. Conclusions: All risk factors that were found in our review imply several categories of contributing factors regarding: (1) delay of care, (2) coordination and management of care, and (3) scarcity of supply, personnel, and knowledge.

Tailoring a sexual health curriculum to the sexual health challenges seen by midwifery, nursing and medical providers and students in Tanzania

BACKGROUND

 Tanzania is a country experiencing multiple sexual health challenges, but providers receive no formal training in sexual health.

AIM

 This study aimed to assess (1) what sexual health challenges are commonly seen in clinics in Tanzania, (2) which are raised by patients, (3) which are not addressed and (4) which topics to prioritise for a sexual health curriculum.

SETTING

 Healthcare settings in Tanzania.

METHODS

 Participants were 60 experienced and 61 student doctors, nurses and midwives working in Dar es Salaam. The authors conducted 18 focus groups stratified by profession (midwifery, nursing or medicine) and experience (practitioners vs. students).

RESULTS

 Providers identified six common sexual health concerns: (1) Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) and sexually transmissible infection (STI) (especially syphilis and gonorrhoea), (2) sexual violence (including intimate partner violence and female genital mutilation), (3) early and unwanted pregnancy (including early sexual debut and complications from abortion), (4) sexual dysfunctions, (5) key population concerns (e.g. lesbian, gay, bisexual, transgender (LGBT); sex work) and (6) non-procreative sexual behaviour (including pornography and masturbation in males and oral and anal sex practices in heterosexual couples). Across professions, few differences were observed. Homosexuality, sex work, masturbation and pornography were identified as taboo topics rarely discussed. Most participants (81%) wanted one comprehensive sexual health curriculum delivered across disciplines.

CONCLUSION

 A sexual health curriculum for health students in Tanzania needs to address the most common sexual health concerns of patients. In addition to teaching sexual science and clinical care, skills training in how to address taboo topics is recommended. Students endorsed almost all sexual health topics, which suggests that a comprehensive curriculum is appropriate.

Does institutional maternity services contribute to the fear of childbirth? A focus group interview study

BACKGROUND

The quality of institutional maternity services offered significantly determine the health outcomes of pregnant women and their infants.

OBJECTIVES

The study aimed at understanding perceptions and experiences of new mothers diagnosed with the fear of childbirth in Kenya; regarding the institutional maternity services offered and if they contribute to the fear of childbirth (FOC).

METHODS

This was a qualitative descriptive study. A total of 29 women who had given birth recently in a maternity institution, and had been screened with the fear of childbirth at 32 weeks' gestation period participated in focus group interviews. The Framework for Assessing the Quality of Care of institutional maternity services (FAQC) developed by the University of Southampton was adopted in this study. Thematic analyses were used.

RESULTS

It was reported that institutional maternity services contributed directly and indirectly to FOC. The direct contribution included the performance of unintended caesarian sections, severe and prolonged labour pains and negative attitude of healthcare providers. The indirect contribution was in form of challenges in the provision of care and the experience of care in the maternity institutions. In the provision of care; human and physical resources, inadequate referral systems, and inadequate management of emergencies were reported. In the experience of care; lack of cognition, respect, dignity, equity and inadequacies in emotional support were reported.

CONCLUSION

The study identified systemic challenges related to both the provision and the experience of care. Therefore, there is need to astutely analyze all critical steps identified in the FAQC, as this will greatly improve the uptake of institutional maternity services.

Legal and Ethical Considerations in the Delivery of Sexual Health Care in Tanzania

Tanzania is a country with multiple sexual health challenges including high rates of HIV/STIs, early sexual debut, forced sex, sexual dysfunction, and teen pregnancy. Training in sexual health care is limited, while courses on how to address the ethical aspects of sexual health are non-existent. To address this gap, this paper explores legal and ethical challenges to providing sexual health care in Tanzania. First, we describe the sexuo-cultural and epidemiologic challenges, and the key laws regulating sexual health. Six case studies identify ethical dilemmas in healthcare delivery. They are: (a) how to address sexual and intimate partner violence; (b) treatment of illegal or stigmatized key populations; (c) treatment of couples in HIV serodiscordant, non-monogamous, and/or polygamous relationships; (d) requests for and participation in illegal healthcare; (e) treatment of women and children in the presence of their husbands and fathers; and (f) addressing child sexual abuse. We apply the ethical principles of autonomy, justice, beneficence and non-malfeasance. A second challenge is ensuring confidentiality in a setting where medical record keeping practices vary widely, and violations to confidentiality are perceived as common. Finally, we identify a set of best practices in sexual healthcare delivery tailored to the Tanzanian context.

Estimating the lifetime incidence of induced abortion and understanding abortion practices in a Northeastern Tanzania community through a household survey

OBJECTIVES

All Tanzanian abortion estimates rely on health facility data that do not take into account completely the incidence of abortion. This papers aims to estimate the lifetime incidence of induced abortion in Arusha, Tanzania via direct and double list-experiment methods using community data and evaluate outcomes and behaviors of women who had an abortion.

METHODS

From January to May 2018, a face-to-face interview survey was conducted on a representative sample of sexually active women (n = 3658) living in Arusha, Tanzania. Participants were selected in a three-stage random process and questions were asked about reproductive history, contraceptive use, and health seeking behaviors. A direct question and double list-experiment was used to estimate lifetime incidence of abortion.

RESULTS

Lifetime abortion incidence was 3% using the direct question compared to 7.7% using the double list-experiment method. However, post-estimation tests revealed a key study design violation thus invalidating list the experiment estimate. We find that 45% of women received their abortion outside the formal health care system, the most frequent method used was manyono pill (traditional medicine), and only 50% of women who experienced abortion complications sought treatment.

CONCLUSIONS

We provide another example of the performance of list experiment in measuring abortion incidence. Nearly half of reported abortions took place outside of the formal health system highlighting the substantial underestimation while using facility data to measure abortion. Seeking health care for potential complications was low despite post-abortion care services being free and legal in Tanzania.

IMPLICATIONS

Using administrative data to estimate lifetime incidence of abortion is inaccurate as we found half of our sample received abortions outside a health facility. Women should be encouraged to seek post-abortion care, when needed.

Is it home delivery or health facility? Community perceptions on place of childbirth in rural Northwest Tanzania using a qualitative approach

BACKGROUND

In low and middle-income countries, pregnancy and delivery complications may deprive women and their newborns of life or the realization of their full potential. Provision of quality obstetric emergency and childbirth care can reduce maternal and newborn deaths. Underutilization of maternal and childbirth services remains a public health concern in Tanzania. The aim of this study was to explore elements of the local social, cultural, economic, and health systems that influenced the use of health facilities for delivery in a rural setting in Northwest Tanzania.

METHODS

A qualitative approach was used to explore community perceptions of issues related to low utilization of health facilities for childbirth. Between September and December 2017, 11 focus group discussions were conducted with women (n = 33), men (n = 5) and community health workers (CHWs; n = 28); key informant interviews were conducted with traditional birth attendants (TBAs; n = 2). Coding, identification, indexing, charting, and mapping of these interviews was done using NVIVO 12 after manual familiarization of the data. Data saturation was used to determine when no further interviews or discussions were required.

RESULTS

Four themes emerge; self-perceived obstetric risk, socio-cultural issues, economic concerns and health facility related factors. Health facility delivery was perceived to be crucial for complicated labor. However, the idea that childbirth was a "normal" process and lack of social and cultural acceptability of facility services, made home delivery appealing to many women and their families. In addition, out of pocket payments for suboptimal quality of health care was reported to hinder facility delivery.

CONCLUSION

Home delivery persists in rural settings due to economic and social issues, and the cultural meanings attached to childbirth. Accessibility to and affordability of respectful and culturally acceptable childbirth services remain challenging in this setting. Addressing barriers on both the demand and supply side could result in improved maternal and child outcomes during labor and delivery.

Beyond the law: Misoprostol and medical abortion in Dar es Salaam, Tanzania

Misoprostol has during the past few years become an important obstetric drug used for different purposes both within and outside hospitals in Tanzania. In this paper, we analyze how misoprostol is perceived, accessed and used off-label as an abortion drug in the city and region of Dar es Salaam. The study took place in Dar es Salaam's three districts from July to November 2015, and had a qualitative explorative approach. We carried out in-depth interviews (42) with the following main categories of informants: women having undergone medical abortion (15), health care workers with experiences from post abortion care (16) and drug vendors (11). Focus group discussions (10) were carried out with young women. A client simulation study was carried out in 64 drugstores across Dar es Salaam assessing the availability of misoprostol and the advice given concerning its use. In addition, shorter qualitative interviews were carried out with representatives of NGOs and public agencies working with sexual and reproductive health issues (17). Our findings reveal that in Dar es Salaam, misoprostol is well known, available and accessed for abortion purposes through drugstores and health providers. Women tend to prefer misoprostol over other abortion methods since it allows for a private, low-cost, safer and less uncomfortable abortion experience. But, while misoprostol facilitates women's agency in the process of seeking abortion, a series of obstacles shaped by a restrictive abortion law and an unregulated pharmaceutical market hinder its safe use. Central obstacles are profit-seeking providers, suboptimal user instructions and poor provider follow-up. In the discussion of the material we draw upon Van der Geest, Hardon and Whyte's concept of the 'social life of pharmaceuticals' and indicate the ways in which misoprostol acts as an agent of change in the social relations connected to abortion.

Differences in Life-Saving Obstetric Hemorrhage Treatments for Women with Abortion Versus Nonabortion Etiologies in Tanzania

Complications from unsafe abortion are among the major causes of preventable maternal morbidity and mortality, which may be compounded by delays and disparities in treatment. We conducted a secondary analysis of women with symptoms of hypovolemic shock secondary to severe obstetric hemorrhage in Tanzania. We compared receipt of three lifesaving interventions among women with abortions versus other maternal hemorrhage etiologies. Interventions included: non-pneumatic anti-shock garment (NASG) (N = 393), blood transfusion (N = 249), and referral to a higher-capacity facility (N = 131). After controlling for severity of disease and other confounders, women with abortion-related hemorrhage and shock had 78 percent decreased odds of receiving NASG (p < 0.001) and 77 percent decreased odds of receiving a blood transfusion (p < 0.001) compared to women with hemorrhage and shock from other etiologies. Our findings suggest that, in Tanzania, women with abortion-related hemorrhage received lower quality of care than women with other hemorrhage etiologies.

Women's Satisfaction With and Perceptions of the Quality of Postabortion Care at Public-Sector Facilities in Mainland Tanzania and in Zanzibar

BACKGROUND

In 2015, the government of Tanzania began to strengthen the quality of postabortion care (PAC). Limited research has been conducted to understand clients' perceptions of public sector provision of PAC. Accordingly, we carried out a mixed-method study between April and July 2016, using client surveys and in-depth interviews, both implemented immediately following PAC. Results were used to help guide the government's initiative.

METHODOLOGY

We assessed the quality of PAC in 25 public-sector facilities through a client survey of 412 women. Questions included satisfaction with client-staff interaction, counseling, provider competence, postabortion family planning, accessibility of care, and the facility environment. Based on responses, we developed and validated a scale representing women's overall satisfaction with the quality of care. We conducted bivariate analysis to identify the levels of care associated with clients' ranking of individual and composite measures of the quality of care. We used multivariate ordinal logistic models to assess the relative influence of multilevel factors on clients' overall satisfaction. We coupled our survey with qualitative analysis of in-depth interviews with 30 PAC clients.

RESULTS

Clients reported moderately high levels of satisfaction with the quality of PAC, with an overall mean score of 2.6 on a 4-point scale. Bivariate analysis identified several areas for improvement, including family planning counseling and provision, especially at regional hospitals; pain management; and reduced use of sharp curettage. The factors most strongly associated with satisfaction were advanced parity, receiving care at lower-level facilities, brief waiting periods, and manual vacuum aspiration for treatment of incomplete abortion. Qualitative analysis illuminated how client-provider interactions; pain; desire for counseling and information, especially on family planning; and congested facility environments shape clients' perceptions of the care they received.

CONCLUSIONS

Although clear areas for improvement in public-sector provision of PAC existed at all sites, women were less likely to report satisfaction with care at referral facilities owing primarily to inadequate counseling, delays in receiving PAC treatment after admission, and poor emphasis on postabortion fertility, family planning information, and contraceptive provision. PAC programs should ensure availability of a wide range of contraceptive methods and high-quality family planning counseling, especially at tertiary facilities.

The Unit and Scale-Up Cost of Postabortion Care in Tanzania

INTRODUCTION

Based on research conducted in 2017, we estimated the cost to the Tanzanian health care system of providing postabortion care (PAC). PAC is an integrated service package that addresses the curative and preventive needs of women experiencing complications from abortion. PAC services include treating complications of miscarriage and incomplete abortion, providing voluntary family planning counseling and services, and engaging the community to reduce future unintended pregnancies and repeat abortions.

METHODS

Thirty-one public and private health facilities, representing 3 levels of health care, were selected for data collection from key care providers and administrators in 3 regions. We gathered data on the direct costs of PAC startup (i.e., training and capital costs), as well as the recurrent costs of medicines, supplies, hospitalization, and personnel, and the indirect costs of PAC provision. We also gathered data to estimate PAC clients' out-of-pocket expenses. Estimates of the average cost per client (i.e., unit cost) were calculated for treatment of routine and severe abortion complications, treatment at different levels of health care, postabortion contraception, and various available treatment methods.

RESULTS

We found that the unit cost of PAC training per provider was US$163.43. The total unit cost was $72.91. The unit recurrent cost of treating routine complications, which included 81% of the cases in our sample, was $36.23. The cost of treating incomplete abortion through manual vacuum aspiration was $22.63, while the cost of treatment with misoprostol was $18.74. The average cost of providing voluntary postabortion family planning was $11.56. We estimated an average client out-of-pocket expenditure on PAC of $22.96.

CONCLUSION

We applied our unit cost estimates to those on PAC utilization and provision and unmet need for PAC that were derived from research conducted in Tanzania in 2013-2016, and we estimated an annual national cost of PAC of $4,170,476. We estimated the cost of providing PAC for all women who have abortion complications, including those who do not access PAC, at $10,426,299. Investing more resources in voluntary family planning and PAC treatment of routine complications at the primary level would likely reduce health system costs.

Analysis of Maternal Near Miss at Tertiary Level Hospitals, Ahmedabad: A Valuable Indicator for Maternal Health Care

BACKGROUND

Complications during pregnancy and childbirth remain a leading cause of illness and death among women of reproductive age in India. In the recent years, the concept of the WHO maternal near miss (MNM) has been adopted by the tertiary level hospitals as it has an added advantage of offering a large number of cases for intervention and for the evaluation of the maternal healthcare being provided by the health-care system.

MATERIALS AND METHODS

In the present study, near miss criterion-based audit of MNM cases and maternal death (MD) cases, based on the WHO near miss approach and MD, was conducted from the record section of the four tertiary level hospitals. In the present study, the WHO MNM approach was adopted to assess the quality of maternal healthcare in tertiary level hospitals. Retrospective secondary data analysis from the records of record section and maternity wards pertaining to June 2015-May 2016, of the hospitals of Ahmedabad city, was conducted from January 2016 to November 2017.

RESULTS

The total number of live births of all the four hospitals under surveillance was 21,491. Severe maternal outcome cases were 326, of which 247 (75.8%) were of MNM cases and 79 (24.2%) were of MD. MNM mortality ratio was found to be 3.13:1. Eclampsia (29.45%) followed by preeclampsia (25.46%) and severe postpartum hemorrhage (22.39%) were the leading causes of potentially life-threatening conditions.

CONCLUSION

Above finding suggests the development of a comprehensive framework for the assessment of MNM and further improvement in the quality of maternal health care.

Latent class analysis of the social determinants of health-seeking behaviour for delivery among pregnant women in Malawi

INTRODUCTION

In the era of Sustainable Development Goals, reducing maternal and neonatal mortality is a priority. With one of the highest maternal mortality ratios in the world, Malawi has a significant opportunity for improvement. One effort to improve maternal outcomes involves increasing access to high-quality health facilities for delivery. This study aimed to determine the role that quality plays in women's choice of delivery facility.

METHODS

A revealed-preference latent class analysis was performed with data from 6625 facility births among women in Malawi from 2013 to 2014. Responses were weighted for national representativeness, and model structure and class number were selected using the Bayesian information criterion.

RESULTS

Two classes of preferences exist for pregnant women in Malawi. Most of the population 65.85% (95% CI 65.847% to 65.853%) prefer closer facilities that do not charge fees. The remaining third (34.15%, 95% CI 34.147% to 34.153%) prefers central hospitals, facilities with higher basic obstetric readiness scores and locations further from home. Women in this class are more likely to be older, literate, educated and wealthier than the majority of women.

CONCLUSION

For only one-third of pregnant Malawian women, structural quality of care, as measured by basic obstetric readiness score, factored into their choice of facility for delivery. Most women instead prioritise closer care and care without fees. Interventions designed to increase access to high-quality care in Malawi will need to take education, distance, fees and facility type into account, as structural quality alone is not predictive of facility type selection in this population.

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

OBJECTIVE

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

DESIGN

Health facility-based cross-sectional survey.

SETTING

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

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Caesarean section audit to improve quality of care in a rural referral hospital in Tanzania

Background

Caesarean section (CS) is often a life-saving procedure, but can also lead to serious complications, even more so in low-resource settings. Therefore unnecessary CS should be avoided and optimal circumstances for vaginal delivery should be created. In this study, we aim to audit indications for Caesarean sections and improve decision-making and obstetric management.

Methods

Audit of all cases of CS performed from January to August 2013 was performed in a rural referral hospital in Tanzania. The study period was divided in three audit blocks; retrospective (before auditing), prospective 1 and prospective 2. A local audit panel (LP) and an external auditor (EA) judged if obstetric management was adequate and indications were appropriate or if CS could have been prevented and yet retain good pregnancy outcome. Furthermore, changes in modes of deliveries, overall pregnancy outcome and decision-to-delivery interval were monitored.

Results

During the study period there were 1868 deliveries. Of these, 403 (21.6%) were Caesarean sections. The proportions of unjustified CS prior to introduction of audit were as high as 34 and 75%, according to the respective judgments of LP and EA. Following introduction of audit, the proportions of unjustified CS decreased to 23% (p = 0.29) and 52% (p = 0.01) according to LP and EA respectively. However, CS rate did not change (20.2 to 21.7%), assisted vacuum delivery rate did not increase (3.9 to 1.8%) and median decision-to-delivery interval was 83 min (range 10 - 390 min).

Conclusions

Although this is a single center study, these findings suggest that unnecessary Caesarean sections exist at an alarming rate even in referral hospitals and suggest that a vast number can be averted by introducing a focused CS audit system. Our findings indicate that CS audit is a useful tool and, if well implemented, can enhance rational use of resources, improve decision-making and harmonise practice among care providers.

Audit for quality of care and fate of maternal critical cases at Women's Health Hospital

Maternal deaths remain high, numbers at the facility level are relatively low.

AIM

To evaluate effect of management guidelines on occurrence of maternal near miss in Women's Health Hospital.

DESIGN

A cross-sectional study.

SETTING

ICU of Women's Health Hospital's at Assiut Main University Hospital and Al-fayoum University Hospital.

SUBJECTS

Convenient sample of 93 maternal near-miss cases including (Pregnancy or postpartum complications). TOOL: audit the applied critical care for severe condition related to obstetric complications and consist of three parts: Patient's demographic data, Audit of critical care and "Maternal near-miss" Fate. Data collected during a period of 1/3/2015 to 30/8/2015 for management guidelines and maternal outcomes.

RESULTS

A statistical significant differences between the medical management and occurrence of sever maternal complications such as (severe postpartum hemorrhage, severe pre-eclampsia, Sepsis or severe systemic infection, uterine hemorrhage, ruptured uterus) (P=0.000, P=0.031, P=0.036, P=0.052, P=0.012 respectively).

CONCLUSIONS

The maternal management guidelines was a successful tool in recording the gap between the current received management and standards management guidelines in ICU. Also they measure the effect of current management in ICU on maternal mortality and morbidity.

Is time of birth a predictor of adverse perinatal outcome? A hospital-based cross-sectional study in a low-resource setting, Tanzania

Background

Inconsistent evidence of a higher risk of adverse perinatal outcomes during off-hours compared to office hours necessitated a search for clear evidence of an association between time of birth and adverse perinatal outcomes.

Methods

A cross-sectional study conducted at a tertiary referral hospital compared perinatal outcomes across three working shifts over 24 h. A checklist and a questionnaire were used to record parturients’ socio-demographic and obstetric characteristics, mode of delivery and perinatal outcomes, including 5th minute Apgar score, and early neonatal mortality. Risks of adverse outcomes included maternal age, parity, referral status and mode of delivery, and were assessed for their association with time of delivery and prevalence of fresh stillbirth as a proxy for poor perinatal outcome at a significance level of p = 0.05.

Results

Off-hour deliveries were nearly twice as likely to occur during the night shift (odds ratio (OR), 1.62; 95% confidence interval (CI), 1.50–1.72), but were unlikely during the evening shift (OR, 0.58; 95% CI, 0.45–0.71) (all p < 0.001). Neonatal distress (O.R, 1.48, 95% CI; 1.07–2.04, p = 0.02), early neonatal deaths (OR, 1.70; 95% CI, 1.07–2.72, p = 0.03) and fresh stillbirths (OR, 1.95; 95% CI, 1.31–2.90, p = 0.001) were more significantly associated with deliveries occurring during night shifts compared to evening and morning shifts. However, fresh stillbirths occurring during the night shift were independently associated with antenatal admission from clinics or wards, referral from another hospital, and abnormal breech delivery (OR 1.9; 95% CI, 1.3–2.9, p = 0.001, for fresh stillbirths; OR, 5.0; 95% CI 1.7–8.3, p < 0.001, for antenatal admission; OR, 95% CI, 1.1–2.9, p < 0.001, for referral form another hospital; and OR 1.6; 95% CI 1.02–2.6, p = 0.004, for abnormal breech deliveries).

Conclusion

Off-hours deliveries, particularly during the night shift, were significantly associated with higher proportions of adverse perinatal outcomes, including low Apgar score, early neonatal death and fresh stillbirth, compared to morning and evening shifts. Labour room admissions from antenatal wards, referrals from another hospital and abnormal breech delivery were independent risk factors for poor perinatal outcome, particularly fresh stillbirths.

Assessing emergency obstetric and newborn care: can performance indicators capture health system weaknesses?

Background

Regular monitoring and assessment of performance indicators for emergency obstetric and newborn care can help to identify priorities to improve health services for women and newborns. The aim of this study was to perform a district wide assessment of emergency obstetric and newborn care performance and identify ways for improvement.

Methods

Facility assessment of 13 dispensaries, four health centers and one district hospital in a rural district in Tanzania was performed in two data collection periods in 2014. Assessment included a facility walk-through to observe facility infrastructure and interviews with facility in-charges to assess available services, staff and supplies. In addition facility statistics were collected for the year 2013. Results were discussed with district representatives.

Results

Approximately 65% of expected births took place in health facilities and 22% of women with complications were treated in facilities expected to provide emergency care. None of the facilities was, however, able to perform at the expected level for emergency obstetric and newborn care since not all required signal functions could be provided. Inadequate availability of essential drugs such as uterotonics, antibiotics and anticonvulsants as well as lack of ability to perform vacuum extraction and blood transfusion limited performance.

Conclusions

Performance of emergency obstetric and newborn care in Magu District was not in accordance with expected guidelines and highly influenced by lack of available resources and an insufficiently functioning health care system. Improving assessment approaches, to look beyond the signal functions, can capture weaknesses in the system and will help to understand poor performance and identify locally applicable ways for improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1282-z) contains supplementary material, which is available to authorized users.

Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania

Objective

In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting.

Methods

A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit.

Results

Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01).

Conclusion

A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.

Provision of harm-reduction services to limit unsafe abortion in Tanzania

OBJECTIVE

To investigate the feasibility of providing harm-reduction services to reduce unsafe abortion in Tanzania.

METHODS

A cross-sectional study was conducted among 110 women who received harm-reduction counseling at a public health center in Dar es Salaam between February 10 and October 10, 2014. Background and clinical information was collected for all women; a subgroup (n=50) undertook a semi-structured survey that measured the type of services women received, women's perception of the services, and pregnancy outcome. The main study outcomes were attendance at the follow-up visit, type and quality of information women received on both visits, and misoprostol use for pregnancy termination.

RESULTS

Overall, 55 (50.0%) women attended follow-up services. Misoprostol was used for induced abortion among 54 (98.2%); 38 (70.4%) of these women had obtained contraception at the follow-up visit. Likelihood of attendance for follow-up was increased among women who were older than 34 years (odds ratio [OR] 2.2, 95% confidence interval [CI] 0.1-35.8), were married (OR 2.1, 95% CI 0.8-5.7), and had a post-primary education level (OR 2.0, 95% CI 0.8-5.3). On average, 44 (87.0%) women received all required information at the initial counseling session and none reported major complications that required hospitalization.

CONCLUSION

Harm-reduction services for unsafe abortion are feasible and acceptable, and could provide an excellent opportunity to fight abortion-related morbidity and mortality in Tanzania.

Abortion experiences among Zanzibari women: a chain-referral sampling study

Background

In Zanzibar, a semi-autonomous region of Tanzania, induced abortion is illegal but common, and fewer than 12 % of married reproductive-aged women use modern contraception. As part of a multi-method study about contraception and consequences of unwanted pregnancies, the objective of this study was to understand the experiences of Zanzibari women who terminated pregnancies.

Methods

The cross-sectional study was set in Zanzibar, Tanzania. Participants were a community-based sample of women who had terminated pregnancies. We carried out semi-structured interviews with 45 women recruited via chain-referral sampling. We report the characteristics of women who have had abortions, the reasons they had abortions, and the methods used to terminate their pregnancies.

Results

Women in Zanzibar terminate pregnancies that are unwanted for a range of reasons, at various points in their reproductive lives, and using multiple methods. While clinical methods were most effective, nearly half of our participants successfully terminated a pregnancy using non-clinical methods and very few had complications requiring post abortion care (PAC).

Conclusions

Even in settings where abortion is illegal, some women experience illegal abortions without adverse health consequences, what we might call ‘safer’ unsafe abortions; these kinds of abortion experiences can be missed in studies about abortion conducted among women seeking PAC in hospitals.

Incidence of Induced Abortion and Post-Abortion Care in Tanzania

BACKGROUND

Tanzania has one of the highest maternal mortality ratios in the world, and unsafe abortion is one of its leading causes. Yet little is known about its incidence.

OBJECTIVES

To provide the first ever estimates of the incidence of unsafe abortion in Tanzania, at the national level and for each of the 8 geopolitical zones (7 in Mainland plus Zanzibar).

METHODS

A nationally representative survey of health facilities was conducted to determine the number of induced abortion complications treated in facilities. A survey of experts on abortion was conducted to estimate the likelihood of women experiencing complications and obtaining treatment. These surveys were complemented with population and fertility data to obtain abortion numbers, rates and ratios, using the Abortion Incidence Complications Methodology.

RESULTS

In Tanzania, women obtained just over 405,000 induced abortions in 2013, for a national rate of 36 abortions per 1,000 women age 15-49 and a ratio of 21 abortions per 100 live births. For each woman treated in a facility for induced abortion complications, 6 times as many women had an abortion but did not receive care. Abortion rates vary widely by zone, from 10.7 in Zanzibar to 50.7 in the Lake zone.

CONCLUSIONS

The abortion rate is similar to that of other countries in the region. Variations by zone are explained mainly by differences in fertility and contraceptive prevalence. Measures to reduce the incidence of unsafe abortion and associated maternal mortality include expanding access to post-abortion care and contraceptive services to prevent unintended pregnancies.

Effectiveness of a Home-Based Counselling Strategy on Neonatal Care and Survival: A Cluster-Randomised Trial in Six Districts of Rural Southern Tanzania

BACKGROUND

We report a cluster-randomised trial of a home-based counselling strategy, designed for large-scale implementation, in a population of 1.2 million people in rural southern Tanzania. We hypothesised that the strategy would improve neonatal survival by around 15%.

METHODS AND FINDINGS

In 2010 we trained 824 female volunteers to make three home visits to women and their families during pregnancy and two visits to them in the first few days of the infant's life in 65 wards, selected randomly from all 132 wards in six districts in Mtwara and Lindi regions, constituting typical rural areas in Southern Tanzania. The remaining wards were comparison areas. Participants were not blinded to the intervention. The primary analysis was an intention-to-treat analysis comparing the neonatal mortality (day 0-27) per 1,000 live births in intervention and comparison wards based on a representative survey in 185,000 households in 2013 with a response rate of 90%. We included 24,381 and 23,307 live births between July 2010 and June 2013 and 7,823 and 7,555 live births in the last year in intervention and comparison wards, respectively. We also compared changes in neonatal mortality and newborn care practices in intervention and comparison wards using baseline census data from 2007 including 225,000 households and 22,243 births in five of the six intervention districts. Amongst the 7,823 women with a live birth in the year prior to survey in intervention wards, 59% and 41% received at least one volunteer visit during pregnancy and postpartum, respectively. Neonatal mortality reduced from 35.0 to 30.5 deaths per 1,000 live births between 2007 and 2013 in the five districts, respectively. There was no evidence of an impact of the intervention on neonatal survival (odds ratio [OR] 1.1, 95% confidence interval [CI] 0.9-1.2, p = 0.339). Newborn care practices reported by mothers were better in intervention than in comparison wards, including immediate breastfeeding (42% of 7,287 versus 35% of 7,008, OR 1.4, CI 1.3-1.6, p < 0.001), feeding only breast milk for the first 3 d (90% of 7,557 versus 79% of 7,307, OR 2.2, 95% CI 1.8-2.7, p < 0.001), and clean hands for home delivery (92% of 1,351 versus 88% of 1,799, OR 1.5, 95% CI 1.0-2.3, p = 0.033). Facility delivery improved dramatically in both groups from 41% of 22,243 in 2007 and was 82% of 7,820 versus 75% of 7,553 (OR 1.5, 95% CI 1.2-2.0, p = 0.002) in intervention and comparison wards in 2013. Methodological limitations include our inability to rule out some degree of leakage of the intervention into the comparison areas and response bias for newborn care behaviours.

CONCLUSION

Neonatal mortality remained high despite better care practices and childbirth in facilities becoming common. Public health action to improve neonatal survival in this setting should include a focus on improving the quality of facility-based childbirth care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01022788.

Maternal mortality and distance to facility-based obstetric care in rural southern Tanzania: a secondary analysis of cross-sectional census data in 226 000 households

BACKGROUND

Access to skilled obstetric delivery and emergency care is deemed crucial for reducing maternal mortality. We assessed pregnancy-related mortality by distance to health facilities and by cause of death in a disadvantaged rural area of southern Tanzania.

METHODS

We did a secondary analysis of cross-sectional georeferenced census data collected from June to October, 2007, in five rural districts of southern Tanzania. Heads of georeferenced households were asked about household deaths in the period June 1, 2004, to May 31, 2007, and women aged 13-49 years were interviewed about birth history in the same time period. Causes of death in women of reproductive age were ascertained by verbal autopsy. We also asked for sociodemographic information. Multilevel logistic regression was used to analyse the effects of distance to health facilities providing delivery care on pregnancy-related mortality (direct and indirect maternal and coincidental deaths).

FINDINGS

The study included 818 583 people living in 225 980 households. Pregnancy-related mortality was high at 712 deaths per 100 000 livebirths, with haemorrhage being the leading cause of death. Deaths due to direct causes of maternal mortality were strongly related to distance, with mortality increasing from 111 per 100 000 livebirths among women who lived within 5 km to 422 deaths per 100 000 livebirths among those who lived more than 35 km from a hospital (adjusted odds ratio 3·68; 95% CI 1·37-9·88). Neither pregnancy-related nor indirect maternal mortality was associated with distance to hospital. Among women who lived within 5 km of a hospital, pregnancy-related mortality was 664 deaths per 100 000 livebirths even though 72% gave birth in hospital and 8% had delivery by caesarean section.

INTERPRETATION

Large distances to hospital contribute to high levels of direct obstetric mortality. High pregnancy-related mortality in those living near to a hospital suggests deficiencies in quality of care.

FUNDING

Bill & Melinda Gates Foundation.

Coverage of emergency obstetric care and availability of services in public and private health facilities in Bangladesh

OBJECTIVE

To assess the coverage of emergency obstetric care (EmOC) and the availability of obstetric services in Bangladesh.

METHODS

In a national health facility assessment performed between November 2007 and July 2008, all public EmOC facilities and private facilities providing obstetric services in the 64 districts of Bangladesh were mapped. The performance of EmOC services in these facilities during the preceding month was investigated using a semi-structured questionnaire completed through interviews of managers and service providers, and record review.

RESULTS

In total, 8.6 (2.1 public and 6.5 private) facilities per 500000 population offered obstetric care services. Population coverage by obstetric care facilities varied by region. Among 281 public facilities designated for comprehensive EmOC, cesarean delivery was available in only 215 (76.5%) and blood transfusion services in 198 (70.5%). In the private sector (for profit and not for profit), these services were available in more than 80% of facilities. In all facility types, performance of assisted vaginal delivery (range 12.2%-48.4%) and use of parenteral anticonvulsants to treat pre-eclampsia/eclampsia (range 48.6%-80.8%) were low. The main reason for non-availability of EmOC services was a lack of specialist/trained providers.

CONCLUSION

Bangladesh needs to increase the availability of EmOC services through innovative public-private partnerships. In the public sector, additional trained manpower supported by an incentivized package should be deployed.

Usual hospital care versus post-abortion care for women with unsafe abortion: a case control study from Sri Lanka

BACKGROUND

Good quality post-abortion-care (PAC) is essential to prevent death and long-term complications following unsafe abortion, especially in countries with restrictive abortion laws. We assessed the PAC given to women following an unsafe abortion, compared to the routine hospital care following spontaneous abortion or unintended pregnancy carried to term in Sri Lanka.

METHODS

A case-control study was conducted in Sri Lanka among 171 cases following unsafe abortion, 638 controls following spontaneous abortion (SA-controls) and 600 women following delivery of an unintended pregnancy (TUP-controls) admitted to same hospitals during the same period. Care provided was assessed using interviewer-administered-questionnaires and in-depth-interviews at hospital discharge and in a sub-sample, at 6-8 weeks post-discharge. Differences in care were assessed using chi-square tests.

RESULTS

Mean age of cases was 30.6 years (SD = 6.6); 21.1% were primis. 60.8% cases developed sepsis and 12.3% organ failure. Cases received timely, complete and safe emergency treatment with no difference to SA-controls (p > 0.05): removal of retained products of conception medically (14.6% cases versus 19.4% SA-controls) or surgically (73.7% versus 75.1%), within 24 hours of admission (63.5% versus 52.8%), under anaesthesia (84.1% versus 92.3%) and intravenous antibiotics (91.2% versus 31.0%). Despite this equitable treatment, cases were dissatisfied with their overall care during hospital stay, predominantly due to verbal harassment of health-care-providers on their abortion status (57.9% versus 19.3% SA-controls, p < 0.05). Ward doctors provided the best care to cases in all aspects, except compared to SA-controls in explaining women's health status (60.2% versus 77.7%), and compared to TUP-controls in providing information on contraceptive methods (14% versus 24.3%), service availability (13.5% versus 24.7%) and assistance in decision-making on contraception (13.5% versus 21.3%). Ward-midwives contributed none to family-planning care of cases. At 6-8 weeks, 48.9% of cases were on contraceptive methods, predominantly short-term, compared to 85.3% of TUP-controls, predominantly long-term methods (p < 0.01).

CONCLUSIONS

Despite equitable emergency treatment, care following unsafe abortion was deficient in post-abortion counselling, education and family planning services. Engagement of public-health staff for follow-up care was inadequate. Perceived dissatisfaction of overall care was owing to discrimination related to their abortion status.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Helping mothers survive bleeding after birth: an evaluation of simulation-based training in a low-resource setting

OBJECTIVE

To evaluate "Helping Mothers Survive Bleeding After Birth" (HMS BAB) simulation-based training in a low-resource setting.

DESIGN

Educational intervention study.

SETTING

Rural referral hospital in Northern Tanzania.

POPULATION

Clinicians, nurse-midwives, medical attendants, and ambulance drivers involved in maternity care.

METHODS

In March 2012, health care workers were trained in HMS BAB, a half-day simulation-based training, using a train-the-trainer model. The training focused on basic delivery care, active management of third stage of labor, and treatment of postpartum hemorrhage, including bimanual uterine compression.

MAIN OUTCOME MEASURES

Evaluation questionnaires provided information on course perception. Knowledge, skills, and confidence of facilitators and learners were tested before and after training.

RESULTS

Four master trainers trained eight local facilitators, who subsequently trained 89 learners. After training, all facilitators passed the knowledge test, but pass rates for the skills test were low (29% pass rate for basic delivery and 0% pass rate for management of postpartum hemorrhage). Evaluation revealed that HMS BAB training was considered acceptable and feasible, although more time should be allocated for training, and teaching materials should be translated into the local language. Knowledge, skills, and confidence of learners increased significantly immediately after training. However, overall pass rates for skills tests of learners after training were low (3% pass rate for basic delivery and management of postpartum hemorrhage).

CONCLUSIONS

The HMS BAB simulation-based training has potential to contribute to education of health care providers. We recommend a full day of training and validation of the facilitators to improve the training.

Maternal near miss and mortality in a rural referral hospital in northern Tanzania: a cross-sectional study

Background

Maternal morbidity and mortality in sub-Saharan Africa remains high despite global efforts to reduce it. In order to lower maternal morbidity and mortality in the immediate term, reduction of delay in the provision of quality obstetric care is of prime importance. The aim of this study is to assess the occurrence of severe maternal morbidity and mortality in a rural referral hospital in Tanzania as proposed by the WHO near miss approach and to assess implementation levels of key evidence-based interventions in women experiencing severe maternal morbidity and mortality.

Methods

A prospective cross-sectional study was performed from November 2009 until November 2011 in a rural referral hospital in Tanzania. All maternal near misses and maternal deaths were included. As not all WHO near miss criteria were applicable, a modification was used to identify cases. Data were collected from medical records using a structured data abstraction form. Descriptive frequencies were calculated for demographic and clinical variables, outcome indicators, underlying causes, and process indicators.

Results

In the two-year period there were 216 maternal near misses and 32 maternal deaths. The hospital-based maternal mortality ratio was 350 maternal deaths per 100,000 live births (95% CI 243–488). The maternal near miss incidence ratio was 23.6 per 1,000 live births, with an overall case fatality rate of 12.9%. Oxytocin for prevention of postpartum haemorrhage was used in 96 of 201 women and oxytocin for treatment of postpartum haemorrhage was used in 38 of 66 women. Furthermore, eclampsia was treated with magnesium sulphate in 87% of all cases. Seventy-four women underwent caesarean section, of which 25 women did not receive prophylactic antibiotics. Twenty-eight of 30 women who were admitted with sepsis received parenteral antibiotics. The majority of the cases with uterine rupture (62%) occurred in the hospital.

Conclusion

Maternal morbidity and mortality remain challenging problems in a rural referral hospital in Tanzania. Key evidence-based interventions are not implemented in women with severe maternal morbidity and mortality. Progress can be made through up scaling the use of evidence-based interventions, such as the use of oxytocin for prevention and treatment of postpartum haemorrhage.

Developing-world disaster research: present evidence and future priorities

OBJECTIVES

The technology and resource-rich solutions of the developed world may not be completely applicable to or replicable in disasters occurring in the developing world. With the current looming hazards of pandemics, climate change, global terrorism and conflicts around the world, policy makers and governments will need high-quality scientific data to make informed decisions for preparedness and mitigation. The evidence on disasters in peer-reviewed journals about the developing world was examined for quality and quantity in this systematic review.

METHODS

PubMed was searched using the Medical Subject Heading (MeSH) terms disasters, disaster medicine, rescue work, relief work, and conflict and then refined using the MeSH term developing country. The final list of selected manuscripts were analyzed by type of article, level of evidence, theme of the manuscript and topic, author affiliation, and region of the study.

RESULTS

After searching and refining, <1% of the citations in PubMed addressed disasters in developing countries. The majority was original research articles or reviews, and most of the original research articles were level IV or V evidence. Less than 25% of the authors were from the developing world. The predominant themes were missions, health care provision, and humanitarian aid during the acute phase of disasters in the developing world.

CONCLUSIONS

Considering that 85% of disasters and 95% of disaster-related deaths occur in the developing world, the overwhelming number of casualties has contributed insignificantly to the world's peer-reviewed literature. Less than 1% of all disaster-related publications are about disasters in the developing world. This may be a publication bias, or it may be a genuine lack of submissions dealing with these disasters. Authors in this part of the world need to contribute to future disaster research through better-quality systematic research and better funding priorities. Aid for sustaining long-term disaster research may be a more useful investment in mitigating future disasters than short-term humanitarian aid missions to the developing world.

Overcoming phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries

BACKGROUND

An obstetric fistula is a traumatic childbirth injury that occurs when labor is obstructed and delivery is delayed. Prolonged obstructed labor leads to the destruction of the tissues that normally separate the bladder from the vagina and creates a passageway (fistula) through which urine leaks continuously. Women with a fistula become social outcasts. Universal high-quality maternity care has eliminated the obstetric fistula in wealthy countries, but millions of women in resource-poor nations still experience prolonged labor and tens of thousands of new fistula sufferers are added to the millions of pre-existing cases each year. This article discusses fistula prevention in developing countries, focusing on the factors which delay treatment of prolonged labor.

DISCUSSION

Obstetric fistulas can be prevented through contraception, avoiding obstructed labor, or improving outcomes for women who develop obstructed labor. Contraception is of little use to women who are already pregnant and there is no reliable screening test to predict obstruction in advance of labor. Improving the outcome of obstructed labor depends on prompt diagnosis and timely intervention (usually by cesarean section). Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. This time interval is often extended by delays in deciding to seek care, delays in arriving at a hospital, and delays in accessing treatment after arrival. Communities can reasonably demand that governments and healthcare institutions improve the second (transportation) and third (treatment) phases of delay. Initial delays in seeking hospital care are caused by failure to recognize that labor is prolonged, confusion concerning what should be done (often the result of competing therapeutic pathways), lack of women's agency, unfamiliarity with and fear of hospitals and the treatments they offer (especially surgery), and economic constraints on access to care.

SUMMARY

Women in resource-poor countries will use institutional obstetric care when the services provided are valued more than the competing choices offered by a pluralistic medical system. The key to obstetric fistula prevention is competent obstetrical care delivered respectfully, promptly, and at affordable cost. The utilization of these services is driven largely by trust.

Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals

OBJECTIVE

To audit the quality of obstetric management preceding emergency caesarean sections for prolonged labour.

DESIGN

A quality assurance analysis of a retrospective criterion-based audit supplemented by in-depth interviews with hospital staff.

SETTING

Two Tanzanian rural mission hospitals.

POPULATION

Audit of 144 cases of women undergoing caesarean sections for prolonged labour; in addition, eight staff members were interviewed.

METHODS

Criteria of realistic best practice were established, and the case files were audited and compared with these. Hospital staff were interviewed about what they felt might be the causes for the audit findings.

MAIN OUTCOME MEASURES

Prevalence of suboptimal management and themes emerging from an analysis of the transcripts.

RESULTS

Suboptimal management was identified in most cases. Non-invasive interventions to potentially avoid operative delivery were inadequately used. When deciding on caesarean section, in 26% of the cases labour was not prolonged, and in 16% the membranes were still intact. Of the women with genuine prolonged labour, caesarean sections were performed with a fully dilated cervix in 36% of the cases. Vacuum extraction was not considered. Amongst the hospital staff interviewed, the awareness of evidence-based guidelines was poor. Word of mouth, personal experience, and fear, especially of HIV transmission, influenced management decisions.

CONCLUSION

The lack of use and awareness of evidence-based guidelines led to misinterpretation of clinical signs, fear of simple interventions, and an excessive rate of emergency caesarean sections.

Stillbirths: what difference can we make and at what cost?

Worldwide, 2·65 million (uncertainty range 2·08 million to 3·79 million) stillbirths occur yearly, of which 98% occur in countries of low and middle income. Despite the fact that more than 45% of the global burden of stillbirths occur intrapartum, the perception is that little is known about effective interventions, especially those that can be implemented in low-resource settings. We undertook a systematic review of randomised trials and observational studies of interventions which could reduce the burden of stillbirths, particularly in low-income and middle-income countries. We identified several interventions with sufficient evidence to recommend implementation in health systems, including periconceptional folic acid supplementation or fortification, prevention of malaria, and improved detection and management of syphilis during pregnancy in endemic areas. Basic and comprehensive emergency obstetric care were identified as key effective interventions to reduce intrapartum stillbirths. Broad-scale implementation of intervention packages across 68 countries listed as priorities in the Countdown to 2015 report could avert up to 45% of stillbirths according to a model generated from the Lives Saved Tool. The overall costs for these interventions are within the general estimates of cost-effective interventions for maternal care, especially in view of the effects on outcomes across maternal, fetal, and neonatal health.

Public health perspectives of preeclampsia in developing countries: implication for health system strengthening

OBJECTIVES

Review of public health perspectives of preeclampsia in developing countries and implications for health system strengthening.

METHODS

Literature from Pubmed (MEDLINE), AJOL, Google Scholar, and Cochrane database were reviewed.

RESULTS

The prevalence of preeclampsia in developing countries ranges from 1.8% to 16.7%. Many challenges exist in the prediction, prevention, and management of preeclampsia. Promising prophylactic measures like low-dose aspirin and calcium supplementation need further evidence before recommendation for use in developing countries. Treatment remains prenatal care, timely diagnosis, proper management, and timely delivery. Prevailing household, community, and health system factors limiting effective control of preeclampsia in these countries were identified, and strategies to strengthen health systems were highlighted.

CONCLUSION

Overcoming the prevailing challenges in the control of preeclampsia in developing countries hinges on the ability of health care systems to identify and manage women at high risk.

Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study

OBJECTIVE

To determine whether training traditional birth attendants to manage several common perinatal conditions could reduce neonatal mortality in the setting of a resource poor country with limited access to healthcare.

DESIGN

Prospective, cluster randomised and controlled effectiveness study.

SETTING

Lufwanyama, an agrarian, poorly developed district located in the Copperbelt province, Zambia. All births carried out by study birth attendants occurred at mothers' homes, in rural village settings.

PARTICIPANTS

127 traditional birth attendants and mothers and their newborns (3559 infants delivered regardless of vital status) from Lufwanyama district.

INTERVENTIONS

Using an unblinded design, birth attendants were cluster randomised to intervention or control groups. The intervention had two components: training in a modified version of the neonatal resuscitation protocol, and single dose amoxicillin coupled with facilitated referral of infants to a health centre. Control birth attendants continued their existing standard of care (basic obstetric skills and use of clean delivery kits).

MAIN OUTCOME MEASURES

The primary outcome was the proportion of liveborn infants who died by day 28 after birth, with rate ratios statistically adjusted for clustering. Secondary outcomes were mortality at different time points; and comparison of causes of death based on verbal autopsy data.

RESULTS

Among 3497 deliveries with reliable information, mortality at day 28 after birth was 45% lower among liveborn infants delivered by intervention birth attendants than control birth attendants (rate ratio 0.55, 95% confidence interval 0.33 to 0.90). The greatest reductions in mortality were in the first 24 hours after birth: 7.8 deaths per 1000 live births for infants delivered by intervention birth attendants compared with 19.9 per 1000 for infants delivered by control birth attendants (0.40, 0.19 to 0.83). Deaths due to birth asphyxia were reduced by 63% among infants delivered by intervention birth attendants (0.37, 0.17 to 0.81) and by 81% within the first two days after birth (0.19, 0.07 to 0.52). Stillbirths and deaths from serious infection occurred at similar rates in both groups.

CONCLUSIONS

Training traditional birth attendants to manage common perinatal conditions significantly reduced neonatal mortality in a rural African setting. This approach has high potential to be applied to similar settings with dispersed rural populations. Trial registration Clinicaltrials.gov NCT00518856.