Maternal morbidity and mortality in two different populations of Senegal: a prospective study (MOMA survey)

Incidence and determinants of maternal sepsis in Ghana in the midst of a pandemic

BACKGROUND

Despite being preventable, maternal sepsis continues to be a significant cause of death and morbidity, killing one in every four pregnant women globally. In Ghana, clinicians have observed that maternal sepsis is increasingly becoming a major contributor to maternal mortality. The lack of a consensus definition for maternal sepsis before 2017 created a gap in determining global and country-specific burden of maternal sepsis and its risk factors. This study determined the incidence and risk factors of clinically proven maternal sepsis in Ghana.

METHODS

We conducted a prospective cohort study among 1476 randomly selected pregnant women in six health facilities in Ghana, from January to September 2020. Data were collected using primary data collection tools and reviewing the client's charts. We estimated the incidence rate of maternal sepsis per 1,000 pregnant women per person-week. Poisson regression model and the cox-proportional hazard regression model estimators were used to assess risk factors associated with the incidence of maternal sepsis at a 5% significance level.

RESULTS

The overall incidence rate of maternal sepsis was 1.52 [95% CI: 1.20-1.96] per 1000 person-weeks. The majority of the participants entered the study at 10-13 weeks of gestation. The study participants' median body mass index score was 26.4 kgm^-2 [22.9-30.1 kgm^-2]. The risk of maternal sepsis was 4 times higher among women who developed urinary tract infection after delivery compared to those who did not (aHR: 4.38, 95% CI: 1.58-12.18, p < 0.05). Among those who developed caesarean section wound infection after delivery, the risk of maternal sepsis was 3 times higher compared to their counterparts (aHR: 3.77, 95% CI: 0.92-15.54, p < 0.05). Among pregnant women who showed any symptoms 14 days prior to exit from the study, the risk was significantly higher among pregnant women with a single symptom (aHR: 6.1, 95% CI: 2.42-15.21, p < 0.001) and those with two or more symptoms (aHR: 17.0, 95% CI: 4.19-69.00, p < 0.001).

CONCLUSIONS

Our findings show a low incidence of maternal sepsis in Ghana compared to most Low and Middle-Income Countries. Nonetheless, Maternal sepsis remains an important contributor to the overall maternal mortality burden. It is essential clinicians pay more attention to ensure early and prompt diagnosis. Factors significantly predicting maternal sepsis in Ghana were additional maternal morbidity, urinary tract infections, dysuria, and multiple symptoms. We recommend that Ghana Health Service should institute a surveillance system for maternal sepsis as a monthly reportable disease.

Methods used to measure maternal mortality in Sub-Saharan Africa from 1980 to 2020: A systematic literature review

BACKGROUND

Gobally, Sub-Saharan Africa (SSA) has the largest maternal mortality burden, but the region lacks accurate data.

OBJECTIVE

To review methods historically used to measure maternal mortality in SSA to inform future study methods.

SEARCH STRATEGY

We searched databases: PubMed, Medline, WorldCat and CINHAL, using keywords "maternal mortality," "pregnancy-related death," "reproductive age mortality," "ratio," "rate," and "risk," using Boolean operators "OR" and "AND" to combine the search terms.

SELECTION CRITERIA

We searched for empirical and analytical studies that: (1) measured maternal mortality levels, (2) were in SSA, (3) reported original results, and (4) were not duplicate studies. We included studies published in English since 1980.

DATA COLLECTION AND ANALYSIS

We screened the studies using titles and abstracts, reading the full text of selected studies. We analyzed the estimates and strengths, and limitations of the methods.

MAIN RESULTS

We identified 96 studies that used nine methods: demographic surveillance (n = 4), health record reviews (n = 18), confidential enquiries and maternal death surveillance and response (n = 7), prospective cohort (n = 9), reproductive age mortality survey (RAMOS) (n = 6), sisterhood method (n = 35), mixed methods (n = 4), and mathematical modeling (n = 13).

CONCLUSION

Sisterhood method studies and RAMOS studies that combined institutional records and community data produced maternal mortality ratios more comparable with WHO estimates.

The cost-effectiveness of using results-based financing to reduce maternal and perinatal mortality in Malawi

INTRODUCTION

Results-based financing (RBF) is being promoted to increase coverage and quality of maternal and perinatal healthcare in sub-Saharan Africa (SSA) countries. Evidence on the cost-effectiveness of RBF is limited. We assessed the cost-effectiveness within the context of an RBF intervention, including performance-based financing and conditional cash transfers, in rural Malawi.

METHODS

We used a decision tree model to estimate expected costs and effects of RBF compared with status quo care during single pregnancy episodes. RBF effects on maternal case fatality rates were modelled based on data from a maternal and perinatal programme evaluation in Zambia and Uganda. We obtained complementary epidemiological information from the published literature. Service utilisation rates for normal and complicated deliveries and associated costs of care were based on the RBF intervention in Malawi. Costs were estimated from a societal perspective. We estimated incremental cost-effectiveness ratios per disability adjusted life year (DALY) averted, death averted and life-year gained (LYG) and conducted sensitivity analyses to how robust results were to variations in key model parameters.

RESULTS

Relative to status quo, RBF implied incremental costs of US$1122, US$26 220 and US$987 per additional DALY averted, death averted and LYG, respectively. The share of non-RBF facilities that provide quality care, life expectancy of mothers at time of delivery and the share of births in non-RBF facilities strongly influenced cost-effectiveness values. At a willingness to pay of US$1485 (3 times Malawi gross domestic product per capita) per DALY averted, RBF has a 77% probability of being cost-effective.

CONCLUSIONS

At high thresholds of wiliness-to-pay, RBF is a cost-effective intervention to improve quality of maternal and perinatal healthcare and outcomes, compared with the non-RBF based approach. More RBF cost-effectiveness analyses are needed in the SSA region to complement the few published studies and narrow the uncertainties surrounding cost-effectiveness estimates.

Institutional delivery service use and associated factors among women who delivered during the last 2 years in Dallocha town, SNNPR, Ethiopia

Aim

To determine the institutional delivery service use and identify factors associated among women who delivered during the last two years in Dallocha town.

Design

A community-based cross-sectional study.

Methods

The study was conducted from 10 March-10 April 2016. A total of 411 study participants were selected by using systematic sampling method. The source population was all reproductive age group mothers. Bivariate and multiple logistic regression was conducted.

Results

Institutional delivery was 304 (74%). Factors associated with increased likelihood of institutional delivery were owning a radio or television, making more than four antenatal care visits, knowing at least one maternity service advantage. Not knowing about at least one benefit institutional delivery decreased the likelihood of institutional delivery.

Conclusion

Three-quarters of the mothers delivered at the health institution. Accordingly, promotion of antenatal care follow-up, in-service training of health professionals and health education is recommended.

Factors associated with severe maternal morbidity in Kelantan, Malaysia: A comparative cross-sectional study

Background

Knowledge on the factors associated with severe maternal morbidity enables a better understanding of the problem and serves as a foundation for the development of an effective preventive strategy. However, various definitions of severe maternal morbidity have been applied, leading to inconsistencies between studies. The objective of this study was to identify the sociodemographic characteristics, medical and gynaecological history, past and present obstetric performance and the provision of health care services as associated factors for severe maternal morbidity in Kelantan, Malaysia.

Methods

A comparative cross-sectional study was conducted in two tertiary referral hospitals in 2014. Postpartum women with severe morbidity and without severe morbidity who fulfilled the inclusion and exclusion criteria were eligible as cases and controls, respectively. The study population included all postpartum women regardless of their age. Pregnancy at less than 22 weeks of gestation, more than 42 days after the termination of pregnancy and non-Malaysian citizens were excluded. Consecutive sampling was applied for the selection of cases and for each case identified, one unmatched control from the same hospital was selected using computer-based simple random sampling. Simple and multiple logistic regressions were performed using Stata Intercooled version 11.0.

Results

A total of 23,422 pregnant women were admitted to these hospitals in 2014 and 395 women with severe maternal morbidity were identified, of which 353 were eligible as cases. An age of 35 or more years old [Adj. OR (95 % CI): 2.6 (1.67, 4.07)], women with past pregnancy complications [Adj. OR (95 % CI): 1.7 (1.00, 2.79)], underwent caesarean section deliveries [Adj. OR (95 % CI): 6.8 (4.68, 10.01)], preterm delivery [Adj. OR (95 % CI): 3.4 (1.87, 6.32)] and referral to tertiary centres [Adj. OR (95 % CI): 2.7 (1.87, 3.97)] were significant associated factors for severe maternal morbidity.

Conclusions

Our study suggests the enhanced screening and monitoring of women of advanced maternal age, women with past pregnancy complications, those who underwent caesarean section deliveries, those who delivered preterm and the mothers referred to tertiary centres as they are at increased risk of severe maternal morbidity. Identifying these factors may contribute to specific and targeted strategies aimed at tackling the issues related to maternal morbidity.

Self-reported postpartum morbidity: prevalence and determinants among women in Marrakesh, Morocco

Background

Maternal mortality is a public health problem particularly in developing countries. This is mainly related to maternal morbidity, especially during the post-partum period (Haemorrhage, infections…). In Morocco, little is known about maternal morbidity within the population. The aim of this study is to determine the prevalence of self-reported postpartum morbidity and grasp its determinants.

Methods

This descriptive and analytic cross-sectional survey was carried out in six health centers drawn randomly in Marrakesh, Morocco. A total of 1,029 women of reproductive age (15–49) giving birth in the year preceding the survey were enrolled. Women were examined in these health centers during the study period.

A questionnaire gathered information about socio-demographic, health and reported postpartum morbidity.

Bivariate and multiple analyses were used to identify associated factors with the self-reported postpartum morbidity. Statistical significance was set at p < 0.05.

Results

The self-reported postpartum morbidity prevalence was 13.1 % while haemorrhage, pregnancy-induced hypertension and fever were the main complications: 71.92 %; 12.18 % and 10.64 % respectively.

According to the multiple logistic regression model, the illiteracy among women and the number of pregnancies greater than 3 determine independently this morbidity (OR = 1.24; CI 95 %: 1.09–1.54; and OR = 1.69; CI 95 %:1.04–2.70 respectively).

Conclusion

Reducing female illiteracy and fertility will help the fight against postpartum maternal morbidity, which is critical to the wellbeing of women and their infants.

Measuring the cost-effectiveness of midwife-led versus physician-led intrapartum teams in developing countries

International agencies have advocated scaling-up of midwifery resources as an important method for improving maternal health and reducing maternal mortality rates (MMR). The cost-effectiveness of midwife-led versus physician-led intrapartum care is an important consideration in the human resource planning required to reduce MMR. Studies suggest that midwife-led teams can achieve comparable effectiveness and outcomes using less medically intensive care compared with physician-led teams. In the absence of adequate medical cost data, decision makers should consider the substantially lower average costs for three main drivers: salaries, benefits and incentives (≥two-times lower); preservice training (three-times lower) and attrition (two-times lower) necessary to deliver intrapartum care at the level of midwife competencies. This suggests that scale-up of midwifery resources is a less expensive and more cost-effective way to reduce MMRs and could potentially increase access to skilled intrapartum care.

Maternal and perinatal mortality by place of delivery in sub-Saharan Africa: a meta-analysis of population-based cohort studies

BACKGROUND

Facility-based delivery has gained traction as a key strategy for reducing maternal and perinatal mortality in developing countries. However, robust evidence of impact of place of delivery on maternal and perinatal mortality is lacking. We aimed to estimate the risk of maternal and perinatal mortality by place of delivery in sub-Saharan Africa.

METHODS

We conducted a systematic review of population-based cohort studies reporting on risk of maternal or perinatal mortality at the individual level by place of delivery in sub-Saharan Africa. Newcastle-Ottawa Scale was used to assess study quality. Outcomes were summarized in pooled analyses using fixed and random effects models. We calculated attributable risk percentage reduction in mortality to estimate exposure effect. We report mortality ratios, crude odds ratios and associated 95% confidence intervals.

RESULTS

We found 9 population-based cohort studies: 6 reporting on perinatal and 3 on maternal mortality. The mean study quality score was 10 out of 15 points. Control for confounders varied between the studies. A total of 36,772 pregnancy episodes were included in the analyses. Overall, perinatal mortality is 21% higher for home compared to facility-based deliveries, but the difference is only significant when produced with a fixed effects model (OR 1.21, 95% CI: 1.02-1.46) and not when produced by a random effects model (OR 1.21, 95% CI: 0.79-1.84). Under best settings, up to 14 perinatal deaths might be averted per 1000 births if the women delivered at facilities instead of homes. We found significantly increased risk of maternal mortality for facility-based compared to home deliveries (OR 2.29, 95% CI: 1.58-3.31), precluding estimates of attributable risk fraction.

CONCLUSION

Evaluating the impact of facility-based delivery strategy on maternal and perinatal mortality using population-based studies is complicated by selection bias and poor control of confounders. Studies that pool data at an individual level may overcome some of these problems and provide better estimates of relative effectiveness of place of delivery in the region.

Maternal near miss: an indicator for maternal health and maternal care

Maternal mortality is one of the important indicators used for the measurement of maternal health. Although maternal mortality ratio remains high, maternal deaths in absolute numbers are rare in a community. To overcome this challenge, maternal near miss has been suggested as a compliment to maternal death. It is defined as pregnant or recently delivered woman who survived a complication during pregnancy, childbirth or 42 days after termination of pregnancy. So far various nomenclature and criteria have been used to identify maternal near-miss cases and there is lack of uniform criteria for identification of near miss. The World Health Organization recently published criteria based on markers of management and organ dysfunction, which would enable systematic data collection on near miss and development of summary estimates. The prevalence of near miss is higher in developing countries and causes are similar to those of maternal mortality namely hemorrhage, hypertensive disorders, sepsis and obstructed labor. Reviewing near miss cases provide significant information about the three delays in health seeking so that appropriate action is taken. It is useful in identifying health system failures and assessment of quality of maternal health-care. Certain maternal near miss indicators have been suggested to evaluate the quality of care. The near miss approach will be an important tool in evaluation and assessment of the newer strategies for improving maternal health.

Social inequality and antenatal care: impact of economic welfare on pregnancy monitoring in Senegal

AIM

To explore the links between antenatal care (ANC) non-attendance and economic welfare. METHOD AND SUBJECT: This was a cross-sectional, descriptive and analytical study of women aged 15 to 49 years living in Senegal in 2005. Data were from the Demography and Health Survey using a two-stage random sampling procedure. Participants were classed by quintile using an economic well-being score based on housing characteristics and ownership of sustainable goods. The quality of ANC was determined from the number of visits, the qualification of the person delivering care, and content (counseling, weight, height and blood pressure measurements). Logistic regression was used for data analysis.

RESULTS

A total of 6927 women were surveyed. Mean age was 28.15 years (±2.6); 20.3% were primiparous; 61.2% resided in rural areas; 70.0% had received no education. Each of the first four economic quintiles included about 20% (19.2% to 21.5%) of the participants while 16.9% were in the fifth (richest) quintile. A total of 457 women (6.6%) did not undergo any ANC visit. ANC non-attendance increased with parity, decreased with education level and was higher in rural areas than in urban areas, OR=7.2 (95% CI [5.1-10.1]). It decreased with increasing economic well-being: OR=0.6 [0.47-0.75] 2nd quintile vs. 1st, OR=0.02 [0.01-0.05] 5th quintile vs. 1st, p<0.05 overall.

CONCLUSION

Economic welfare plays a major role in determining use of ANC. The only way to solve health problems is to reduce inequalities. The solution to this problem is beyond the scope of health but concerns an overall economic program involving the entire community, including policy-makers.

Knowledge of symptoms and signs of puerperal sepsis in a community in north-eastern Nigeria: a cross-sectional study

Puerperal sepsis is a leading cause of mortality in developing countries. The objective of this study is to determine the knowledge of symptoms and signs of puerperal sepsis. It was a cross-sectional community-based study. Of the 400 respondents interviewed, 289 (72.2%) were between the ages of 20 and 39 years, and most, 374 (93.5%), were married. Only 14 (3.5%) had tertiary education. Most respondents, 224 (56.0%) were farmers and grandmultiparae accounted for 187 (46.7%). A reassuring number of respondents, 265 (66.3%), knew that fever with abnormal vaginal discharge; 252 (63%) fever with foul smelling lochia; 346 (86.4%) fever occurring with lower abdominal pain and 182 (45.5%) knew that fever occurring with prolonged flow of lochia, are all indicators of puerperal sepsis. A total of 53% of respondents were not aware of the causes of puerperal sepsis; 10% believed it is caused by evil spirits. The knowledge of the causes of puerperal sepsis is poor. There is the need to put more emphasis on the causes of puerperal sepsis during antenatal health talks. This could help reduce morbidity and mortality associated with puerperal sepsis.

Childbirth attendance strategies and their impact on maternal mortality and morbidity in low-income settings: a systematic review

OBJECTIVE

To review quantitative evidence of the effect on maternal health of different childbirth attendance strategies in low-income settings.

DESIGN

Systematic review.

METHODS

Studies using quantitative methods, referring to the period 1987-2011, written in English and reporting the impact of childbirth attendance strategies on maternal mortality or morbidity in low-income settings were included. Guidelines developed by the Cochrane collaboration and the Centre for Review and Dissemination, University of York were followed. The included articles were read and sorted by category of strategy that emerged from the reading.

RESULTS

The search criteria yielded 29 articles. The following three main categories of strategy emerged: (i) those primarily intended to improve quality of care; (ii) "centrifugal strategies," which sought to bring services to the women; and (iii) "centripetal strategies," which sought to bring the women to the services. Few of the studies had a design that provided strong evidence for the impact of the strategy concerned.

CONCLUSIONS

The evidence emerging from the studies was difficult to compare, because concepts were not defined in a consistent manner (such as "skilled birth attendance") and many studies examined the impact of a package of interventions without ferreting out the impact of individual components. Yet, some studies described individual aspects with great promise (such as cost, transport, outreach-friendly drugs or targeted training). There is a need for clearer conceptual frameworks, including some which permit assessment of packages of interventions.

Systematic review of the magnitude and case fatality ratio for severe maternal morbidity in sub-Saharan Africa between 1995 and 2010

BACKGROUND

Analysis of severe maternal morbidity (maternal near misses) provides information on the quality of care. We assessed the prevalence/incidence of maternal near miss, maternal mortality and case fatality ratio through systematic review of studies on severe maternal morbidity in sub-Saharan Africa.

METHODS

We examined studies that reported prevalence/incidence of severe maternal morbidity (maternal near misses) during pregnancy, childbirth and postpartum period between 1996 and 2010. We evaluated the quality of studies (objectives, study design, population studied, setting and context, definition of severe acute obstetric morbidity and data collection instruments). We extracted data, using a pre-defined protocol and criteria, and estimated the prevalence or incidence of maternal near miss. The case-fatality ratios for reported maternal complications were estimated.

RESULTS

We identified 12 studies: six were cross-sectional, five were prospective and one was a retrospective review of medical records. There was variation in the setting: while some studies were health facility-based (at the national referral hospital, regional hospital or various district hospitals), others were community-based studies. The sample size varied from 557 women to 23,026. Different definitions and terminologies for maternal near miss included acute obstetric complications, severe life threatening obstetric complications and severe obstetric complications. The incidence/prevalence ratio and case-fatality ratio for maternal near misses ranged from 1.1%-10.1% and 3.1%-37.4% respectively. Ruptured uterus, sepsis, obstructed labor and hemorrhage were the commonest morbidities that were analyzed. The incidence/prevalence ratio of hemorrhage ranged from 0.06% to 3.05%, while the case fatality ratio for hemorrhage ranged from 2.8% to 27.3%. The prevalence/incidence ratio for sepsis ranged from 0.03% to 0.7%, while the case fatality ratio ranged from 0.0% to 72.7%.

CONCLUSION

The incidence/prevalence ratio and case fatality ratio of maternal near misses are very high in studies from sub-Saharan Africa. Large differences exist between countries on the prevalence/incidence of maternal near misses. This could be due to different contexts/settings, variation in the criteria used to define the maternal near misses morbidity, or rigor used carrying out the study. Future research on maternal near misses should adopt the WHO recommendation on classification of maternal morbidity and mortality.

[Factors determining the place of delivery in women who attended at least one antenatal consultation in a health facility (Senegal)]

BACKGROUND

Home birth remains a major cause of maternal and neonatal deaths in Senegal. The objective of this study was to identify the determinants of home birth in women who attended at least one antenatal consultation during their last pregnancy.

METHOD

The study was cross-sectional and analytical. It covered a sample of 380 women selected at random among those who have given birth in the last 12 months in the health district Gossas. Data were collected at home using a questionnaire during an interview after informed consent. Multiple logistic regression was used to explore the determinants of childbirth at home using the Andersen model.

RESULTS

The mean age was 26.2 ± 6.1 years. Women were married (97.3%), illiterate (81.8%) and lived in rural areas (78.4%). Available means of transportation at home were car (7.6%), cart (62.9%) or none 29.5%. In addition, 52.2% of the women lived more than 5 km from a health facility. For 59.0% of the women, the prenatal exam was considered satisfactory. The prevalence of home birth was 24%. Factors related to birth at home are polygamous marriage (OR=2.04 [1.13-3.70]), lack of transportation (OR=2.11 [1.13-5.01]) and residence more than 5 km from a health facility (OR=2.68 [1.56-4.16]). Late (3.90 [2.30-6.65]) or low quality (4.27 [2.25-8.10]) prenatal exams were also risk factors.

CONCLUSION

Home birth is linked to access to health facilities but also to the prenatal consultation. Particular emphasis should be placed on training health care providers to improve the quality of the patients in the structures.

The relationship between birth with a health professional and maternal mortality in observational studies: a review of the literature

OBJECTIVE

To examine the nature of the association between maternal mortality and birth with a health professional in observational studies.

METHODS

Review of ecological studies relating the overall proportion of births with a health professional with the maternal mortality ratio at national level, and studies exploring the relationship between the presence of a health professional at birth and the risk of dying at the individual level. We report methodological challenges, including data quality and sources and the analytical approaches used. For the individual studies, crude odds ratios and 95% confidence intervals were calculated.

RESULTS

The 10 ecological studies are largely descriptive, a causal inference is tentative and there is poor controlling of confounders. The 10 individual studies examining the risk of death with and without a health professional showed little evidence that giving birth with a health professional reduces a woman's risk of dying, and in some settings it appears to be associated with an increased risk of death.

CONCLUSIONS

None of these study designs are optimal in evaluating the impact of births with a health professional on reducing maternal mortality. Analytically, greater insights can be gained by examining ecological relationships within countries, and by complementing the individual analyses with information on the health status of women when they first reach the health professional and whether or not the women planned to have a health professional present during birth.

Risk factors for obstetric fistula in the Far North Province of Cameroon

OBJECTIVE

To describe the circumstances of occurrence and identify potential risk factors for obstetric fistula in northern Cameroon.

METHODS

A case series study of 42 obstetric fistula patients seeking services at the Provincial Hospital of Maroua, Cameroon, between May 2005 and August 2007. Structured interviews were conducted prior to surgical intervention.

RESULTS

Among obstetric fistula patients, 60% had lived with obstetric fistula for more than 5 years at the time of surgery. Eighty-one percent of patients had received no formal education and 86% were teenagers at their first delivery. Regarding the pregnancy and delivery preceding the occurrence of the fistula, 50% of women reported that they had received no prenatal care and 76% were in labor for more than 12 hours. The majority (83%) of women delivered a stillborn baby.

CONCLUSIONS

Obstetric fistula patients in the Far North Province of Cameroon had a low level of education, were married at a young age, and had poor access to quality maternal healthcare services.

Audit of severe acute morbidity in hypertensive pregnancies in a developing country

The aim of this study was to establish a population-based incidence of severe acute maternal morbidity (SAMM) in hypertensive pregnancies and to assess if substandard care was unique to cases of SAMM and mortality or whether it was apparent in uncomplicated pregnancies as well. The population-based incidence of hypertension was 12%. Using defined criteria for SAMM, the incidence of SAMM was 3/1000 deliveries. The MMR was 42/100000 deliveries, i.e. SAMM is seven times greater than the mortality. Substandard care was similar in cases of SAMM and mortality and uncomplicated hypertensive patients. Audit of SAMM is informative, can be conducted more frequently, and in small sample population groups. It also allows interviews of patients, hence problems of inefficient documentation is obviated.

Systematic review of effect of community-level interventions to reduce maternal mortality

BACKGROUND

The objective was to provide a systematic review of the effectiveness of community-level interventions to reduce maternal mortality.

METHODS

We searched published papers using Medline, Embase, Cochrane library, CINAHL, BNI, CAB ABSTRACTS, IBSS, Web of Science, LILACS and African Index Medicus from inception or at least 1982 to June 2006; searched unpublished works using National Research Register website, metaRegister and the WHO International Trial Registry portal. We hand searched major references.Selection criteria were maternity or childbearing age women, comparative study designs with concurrent controls, community-level interventions and maternal death as an outcome. We carried out study selection, data abstraction and quality assessment independently in duplicate.

RESULTS

We found five cluster randomised controlled trials (RCT) and eight cohort studies of community-level interventions. We summarised results as odds ratios (OR) and confidence intervals (CI), combined using the Peto method for meta-analysis. Two high quality cluster RCTs, aimed at improving perinatal care practices, showed a reduction in maternal mortality reaching statistical significance (OR 0.62, 95% CI 0.39 to 0.98). Three equivalence RCTs of minimal goal-oriented versus usual antenatal care showed no difference in maternal mortality (1.09, 95% CI 0.53 to 2.25). The cohort studies were of low quality and did not contribute further evidence.

CONCLUSION

Community-level interventions of improved perinatal care practices can bring about a reduction in maternal mortality. This challenges the view that investment in such interventions is not worthwhile. Programmes to improve maternal mortality should be evaluated using randomised controlled techniques to generate further evidence.

Revisão sistemática sobre morbidade materna near miss

Esta revisão sistemática sobre near miss materna objetivou analisar dados de incidência e as definições adotadas de near miss. Procedeu-se uma busca eletrônica em bancos de periódicos científicos e também das referências bibliográficas dos estudos identificados. Foram identificados inicialmente 1.247 estudos, analisados na íntegra 35, sendo 17 excluídos e 18 incluídos. A revisão da lista de referências destes artigos identificou mais vinte, totalizando assim 38 estudos incluídos: vinte com definições de near miss relacionadas à complexidade do manejo, seis de disfunção orgânica, dois com definição mista e dez pela presença de sinais ou entidades clínicas específicas. A razão de near miss média foi de 8,2/mil partos, o índice de mortalidade materna foi 6,3% e a razão caso:fatalidade de 16:1. Conclui-se que a incidência de near miss tende a ser maior nos países em desenvolvimento e quando utilizada a definição de disfunção orgânica. O estudo da morbidade materna near miss pode contribuir para a melhora da atenção obstétrica e subsidiar o combate à morte materna.

Emergency obstetric care in developing countries: impact of guidelines implementation in a community hospital in Senegal

OBJECTIVE

To evaluate, with volunteer professionals in a resource-poor setting, an approach of audit and feedback to promote local implementation of emergency obstetric guidelines.

DESIGN

Triple cohort observational time series study.

SETTING

A 46-bed obstetric unit in an academic-affiliated community hospital in Senegal.

POPULATION

All pregnant women with haemorrhagic and hypertensive complications who were admitted to the maternity unit during the study periods.

METHODS

To assess the benefits of guidelines implementation, maternal outcomes during the intervention period were compared with those occurring in two one-year periods when staff daily supervision was the main potentially effective action on clinical management.

MAIN OUTCOME MEASURES

The intervention strategy was criteria-based audits with regular feedback over a one-year period. The clinical focus was haemorrhage and hypertension the most frequent causes of maternal death in the study population. Hospital charts were audited by external reviewers. The primary outcome was the case fatality rate (CFR) among patients with haemorrhage and hypertension.

RESULTS

There was an increase in morbidity diagnoses during the intervention period. In addition, there was a marked increase in obstetric interventions, especially for transfusions and caesarean deliveries. Patients characteristic-adjusted case fatality decreased by 53% between baselines I and II and during the intervention period by 33% and 24%, compared with baseline periods I and II, respectively. Outcome improvements were different for haemorrhage and hypertension.

CONCLUSION

While staff daily supervision may have improved maternal outcome before the intervention period, audit and feedback produced marked effects on emergency obstetric care, specially for complications requiring highly trained management (e.g. pre-eclampsia). Audit and feedback are one of the potentially effective guidelines implementation strategies that should be considered for further studies in resource-poor health facilities.

Intrauterine infection after delivery: a marker of HIV-1 seropositivity among puerperal women in Uganda?

A case controlled study about HIV seroprevalence among women with post-partum endometritis-myometritis (PPEM) matched with two controls. Each was performed in a non-governmental organization hospital in Kampala, Uganda. All participants were offered HIV pre- and post-test counselling. Personal and clinical information was obtained and HIV-1 ELISA tests performed on blood samples and discordant results resolved by Western blot test. HIV-1 seroprevalence was significantly higher among women with PPEM than controls, 26 (42.3%) and 26 (21.3%) respectively (P = 0.002). Women with PPEM were two-and-a-half times more likely to be HIV-positive than controls, odds ratio 2.74 (95% CI 1.34-5.65). Single or cohabiting women and low salaried women were also significantly more among PPEM cases than controls. In conclusion, PPEM cases had significantly higher seroprevalence of HIV-1 infection than controls and this needs further elucidation for purposes of management strategies.

Maternal mortality and access to obstetric services in West Africa

OBJECTIVES

Process evaluation has become the mainstay of safe motherhood evaluation in developing countries, yet the extent to which indicators measuring access to obstetric services at the population level reflect levels of maternal mortality is uncertain. In this study we examine the association between population indicators of access to obstetric care and levels of maternal mortality in urban and rural West Africa.

METHODS

In this ecological study we used data on maternal mortality and access to obstetric services from two population-based studies conducted in 16 sites in eight West African countries: the Maternal Mortality and Obstetric Care in West Africa (MAMOCWA) study in rural Sénégal, Guinea-Bissau and The Gambia and the Morbidité Maternelle en Afrique de l'Ouest (MOMA) study in urban Burkina Faso, Côte d'Ivoire, Mali, Mauritanie, Niger and Sénégal.

RESULTS

In rural areas, maternal mortality, excluding early pregnancy deaths, was 601 per 100,000 live births, compared with 241 per 100,000 for urban areas [RR = 2.49 (CI 1.77-3.59)]. In urban areas, the vast majority of births took place in a health facility (83%) or with a skilled provider (69%), while 80% of the rural women gave birth at home without any skilled care. There was a relatively close link between levels of maternal mortality and the percentage of births with a skilled attendant (r = -0.65), in hospital (r = -0.54) or with a Caesarean section (r = -0.59), with marked clustering in urban and rural areas. Within urban or rural areas, none of the process indicators were associated with maternal mortality.

CONCLUSION

Despite the limitations of this ecological study, there can be little doubt that the huge rural-urban differences in maternal mortality are due, at least in part, to differential access to high quality maternity care. Whether any of the indicators examined here will by themselves be good enough as a proxy for maternal mortality is doubtful however, as more than half of the variation in mortality remained unexplained by any one of them.

Near misses: a useful adjunct to maternal death enquiries

In developed countries where maternal death is rare, the factors surrounding the death are often peculiar to the event and are not generalizable, making analysis of maternal deaths less useful. Near misses are defined as pregnant women with severe life-threatening conditions who nearly die but, with good luck or good care, survive. Incorporation of near misses into maternal death enquiries would strengthen these audits by allowing for more rapid reporting, more robust conclusions, comparisons to be made with maternal deaths, reinforcing lessons learnt, establishing requirements for intensive care and calculating comparative indices. The survival of a pregnant woman is dependent on the disease, her basic health, the health care facilities and personnel of the health care system. The criteria currently used to identify a near miss vary greatly. However, areas with similar health care facilities, medical records and personnel should be able to agree on suitable criteria, making their incorporation into maternal death enquiries feasible.

Skilled attendants for pregnancy, childbirth and postnatal care

This paper sets out the rationale for ensuring that all pregnant women have access to skilled health care practitioners during pregnancy and childbirth. It describes why increasing access to a skilled attendant, especially at birth, is not only based on legitimate demand and clinical common sense, but is also cost-effective and feasible in resource-poor countries. Skilled attendants need to be supported by a health system providing a legal and policy infrastructure, an effective referral system and the supplies that are necessary for effective care. A skilled attendant providing skilled care will help achieve the goals of reducing both maternal and child mortality. Health care professionals as individual practitioners, leaders and informers have an important role in making this a reality.

Can clinical risk factors for late stillbirth in West Africa be detected during antenatal care or only during labour?

BACKGROUND

Recent studies have shown that the most important risk factors for perinatal mortality in developing countries are not detectable during antenatal care but can be observed only shortly before or during labour. Although 60% of perinatal deaths in these countries are stillbirths, few epidemiological studies focus on them. We tested the hypothesis that the risk factors for late stillbirth in West Africa are detectable principally shortly before or during labour.

METHODS

Data came from a prospective population-based study (the MOMA survey) that collected information about 20 326 pregnant women in seven areas, primarily urban, in West Africa.

RESULTS

There were 19 870 singleton births. The stillbirth rate was 25.9 per 1000 total births (95% CI: 23.7-28.1). In the crude analysis, after adjustment and consideration of prevalence, the principal risk factors for late stillbirth were: late antenatal or intrapartum vaginal bleeding, intrapartum hypertension, dystocia, and infection. Other risk factors were: maternal height (<150 cm), maternal age (>35 years), previous stillbirths, hypertension at the 8-month antenatal visit and number of antenatal visits (<2).

CONCLUSIONS

The principal risk factors for late stillbirth observed in our study could be detected only in the late antenatal and intrapartum period. These results highlight the potential benefits of partograph use. They need to be confirmed by studies incorporating continuous intrapartum fetal monitoring.

Levels and causes of maternal mortality in Senegal

OBJECTIVES

To report the findings of a direct, community-based, assessment of maternal mortality and medical causes of death using verbal autopsy in three unique cohorts in rural Senegal.

METHODS

Methods from ongoing demographic surveillance systems. We obtained records of all deaths and births in women of age 15-49 over a period of 14 years in Niakhar, 10 years in Bandafassi and 13 years in Mlomp. Relatives of all women who died were interviewed using a standard questionnaire. Causes of death were assigned by three physicians independently. Maternal deaths were defined according to the ninth and tenth revisions of the International Classification of Diseases.

RESULTS

The maternal mortality ratio was similar in Mlomp [436 per 100 000 live births (95% confidence interval 209-802)] and Niakhar [516 per 100 000 (413-636)] but significantly higher in the more remote area of Bandafassi [852 (587-1196)] [relative risk compared with Niakhar 1.6 (1.0-2.4)]. Two-thirds of the maternal deaths were from direct obstetric causes, haemorrhage being the most common. Abortion was rare.

CONCLUSIONS

Demographic surveillance systems are useful tools for the measurement of maternal mortality provided special studies are carried out to arrive at the levels and causes of maternal death. The estimates of maternal mortality reported here are lower than those published by the WHO and UNICEF but remain extremely high, particularly in the very remote areas with very limited health infrastructure, where as many as one in 19 women may be expected to die as a consequence of childbirth.

Severe obstetric morbidity

Obstetric morbidity is an important marker of the quality of obstetric care. This review explores the definition, incidence and significance of obstetric morbidity. Some topical issues related to obstetric morbidity are discussed. In addition, the importance of long-term morbidity and violence against women is highlighted.

Dystocia: a study of its frequency and risk factors in seven cities of west Africa

OBJECTIVES

To determine the incidence of dystocia in seven west African cities, to attempt to discover what, if any, factors at the prenatal visit might identify women at risk of dystocia, and to assess the utility of such screening.

METHOD

This prospective population study of 20326 pregnant women in west Africa (MOMA) analyzed risk factors for dystocia on the basis of deliveries in health care facilities.

RESULTS

Incidence of dystocia was 18.3%. In the multivariate analysis, the risk factors were small stature, previous cesarean, and nulliparity. As screening tools these factors have inadequate positive predictive values, either singly or combined.

CONCLUSION

It is almost impossible to predict the occurrence of dystocia before the onset of labor. Therefore, labor must be carefully monitored, and there must be health care facilities available that can manage complications, especially cesarean deliveries. If such facilities are not accessible, an effective referral system must be established.

Strategies to reduce maternal mortality worldwide

The challenge of reducing maternal mortality is increasingly being addressed by area-based efforts to improve access to care of obstetric emergencies. Improving coverage and quality of skilled attendance at birth is also being increasingly emphasized. Post-abortion care, better reproductive health services for adolescents, and improved family planning care are important ingredients in maternal mortality reduction. New developments in malaria, nutrition, violence and HIV/AIDS in relation to maternal health are highlighted, as well as measurement issues. Maternal mortality reduction is also being promoted today by using a human rights approach.