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

Field report: ambulance service in Ukraine during weaponized conflict

Crises require changes to established structures, and this also applies to ambulance services. This case report addresses the Ukrainian ambulance service and the changes resulting from the armed conflict in Ukraine. The purpose of this article is to provide insight into the activities of the ambulance service of the Kharkiv region, the second-largest city in Ukraine. Kharkiv is still under heavy fire.

Recommendations to improve maternal mortality among Rohingya women in Bangladeshi refugee camps

Despite current humanitarian efforts, The Rohingya in Bangladesh's refugee camps have among the highest maternal mortality worldwide. The authors review maternal mortality within Rohingya refugee populations in Bangladesh, citing the camp conditions and cultural norms that affect the Maternal Mortality Ratio (MMR). Next, the authors review current humanitarian efforts made by the UNFPA toward improving reproductive health. Finally, the authors recommend a three-pronged approach to reducing maternal mortality among the Rohingya in Bangladeshi refugee camps. We suggest using Maternity Waiting Homes, Mama Rickshaws, and Traditional Birth Attendants to improve maternal health. These solutions address the three-delays model and place ownership into the community. Ultimately, the authors address a much-needed gap in the literature addressing Rohingya maternal mortality.

Framework for maternal morbidity and mortality interventions in Ethiopia: a systematic review protocol

BACKGROUND

Maternal morbidity and mortality remain critical public health challenges in Ethiopia with limited evidence on the effectiveness of interventions and health promotion strategies. A scoping review of the existing literature on maternal morbidity and mortality interventions and health promotion in Ethiopia can provide a comprehensive overview of the current evidence, identify research gaps and establish a framework for successful maternal morbidity and mortality interventions.

OBJECTIVE

The systematic review seeks to assess the existing literature on maternal morbidity and mortality interventions in Ethiopia to develop an evidence-based framework for effective interventions.

METHOD

The methodology for this study adheres to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines for systematic review protocol. A comprehensive search strategy will be devised, in compliance with the highly sensitive search guidelines of Cochrane, which will involve using both snowball methods to identify relevant articles and searching electronic databases using specific key search terms. The following databases will be searched for studies to be included in the systematic review: MEDLINE (via PubMed), Embase, Scopus, Google Scholar, Web of Science, Science Direct and African Journals Online (AJOL).The search will be restricted to English language publications starting from January 2010 to May 2023. In a comprehensive review process, independent reviewers will meticulously assess titles, abstracts and full texts of studies, ensuring alignment with predetermined inclusion and exclusion criteria at each stage of selection.Quality evaluation instruments appropriate for each research design will be used to assess the quality of the selected studies. The findings from the included studies will be analysed and summarised using a narrative synthesis approach.

ETHICS AND DISSEMINATION

Since this systematic review is based on the reviewing of existing literature and will not involve the collection of primary data, ethical approval is not required. The results will be disseminated through peer-reviewed publication and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42023420990.

In-Hospital Obstetric Delays in Rural Uganda: A Cross-Sectional Analysis of a Hospital Cohort

BACKGROUND

Deaths related to pregnancy and childbirth are extremely high in low-resource countries such as Uganda. Maternal mortality in low- and middle-income countries is related to delays in seeking, reaching, and receiving adequate health care. This study aimed to investigate the in-hospital delays to surgical care for women in labor arriving to Soroti Regional Referral Hospital (SRRH).

METHODS

From January 2017 to August 2020, we collected data on obstetric surgical patients in labor using a locally developed, context-specific obstetrics surgical registry. Data regarding patient demographics, clinical and operative characteristics, as well as delays in care and outcomes were documented. Descriptive and multivariate statistical analyses were conducted.

RESULTS

A total of 3189 patients were treated during our study period. Median age was 23 years, most gestations were at term (97%) at the time of operation, and nearly all patients underwent Cesarean Section (98.8%). Notably, 61.7% of patients experienced at least one delay in their surgical care at SRRH. Lack of surgical space was the greatest contributor to delay (59.9%), followed by lack of supplies or personnel. The significant independent predictors of delayed care were having a prenatal acquired infection (AOR 1.73, 95% CI 1.43-2.09) and length of symptoms less than 12 h (AOR 0.32, 95% CI 0.26-0.39) or greater than 24 h (AOR 2.61, 95% CI 2.18-3.12).

CONCLUSION

In rural Uganda, there is a significant need for financial investment and commitment of resources to expand surgical infrastructure and improve care for mothers and neonates.

Readiness of rural health facilities to provide immediate postpartum care in Uganda

BACKGROUND

Nearly 60% of maternal and 45% of newborn deaths occur within 24 h after delivery. Immediate postpartum monitoring could avert death from preventable causes including postpartum hemorrhage, and eclampsia among mothers, and birth asphyxia, hypothermia, and sepsis for babies. We aimed at assessing facility readiness for the provision of postpartum care within the immediate postpartum period.

METHODS

A cross-sectional study involving 40 health facilities within the greater Mpigi region, Uganda, was done. An adapted health facility assessment tool was employed in data collection. Data were double-entered into Epi Data version 4.2 and analyzed using STATA version 13 and presented using descriptive statistics.

RESULTS

Facility readiness for the provision of postpartum care was low (median score 24% (IQR: 18.7, 26.7). Availability, and use of up-to-date, policies, guidelines and written clinical protocols for identifying, monitoring, and managing postpartum care were inconsistent across all levels of care. Lack of or non-functional equipment poses challenges for screening, diagnosing, and treating postnatal emergencies. Frequent stock-outs of essential drugs and supplies, particularly, hydralazine, antibiotics, oxygen, and blood products for transfusions were more common at health centers compared to hospitals. Inadequate human resources and sub-optimal supplies inhibit the proper functioning of health facilities and impact the quality of postpartum care. Overall, private not-for-profit health facilities had higher facility readiness scores.

CONCLUSIONS

Our findings suggest sub-optimal rural health facility readiness to assess, monitor, and manage postpartum emergencies to reduce the risk of preventable maternal/newborn morbidity and mortality. Strengthening health system inputs and supply side factors could improve facility capacity to provide quality postpartum care.

Quality and timeliness of emergency obstetric care and its association with maternal outcome in Keren Hospital, Eritrea

Despite the critical role quality comprehensive emergency obstetric care (CEmOC) plays in ensuring safe motherhood, only a few studies have attempted to measure the impact of substandard and delayed care on maternal outcome thus far. This study evaluates the association between various process and timeliness indicators of CEmOC and adverse maternal outcome in Keren Hospital. This study compared women with potentially life-threatening condition (PLTC) and women with severe maternal outcome (SMO) with respect to various process and timeliness indicators. Logistic regression analysis was employed to assess the association of timeliness and process indicators with SMO using SPSS version-22 computer software. In this study, we included 491 cases of PLTC and 210 cases of SMO (171 maternal near misses and 39 maternal deaths). The following process indicators showed significant association with SMO: failure to give uterotonics for the treatment of postpartum hemorrhage, failure to administer prophylactic antibiotics, and delayed laporatomy for uterine rupture. Moreover, delays in referral, triaging, seeing an obstetrician, and receiving definitive treatement were strongly associated with SMO. The following causes of delay were also found to be independently associated with SMO: erroneous diagnosis, inappropriate management, multiple referrals between health facilities, unavailability of a senior obstetrician, and poor communication during referral. Among the miscellaneous factors, nighttime admission and referral during the rainy season showed significant association with SMO. Findings of this study indicate that huge gap exists in providing quality and timely care in Keren Hospital. In general, most incidents of substandard and delayed care were due to poor referral system, insufficiency of medical staff, inadequacy of drugs and equipment, and unavailability of standard management protocol. Improving the referral system, upgrading the technical skills of health professionals, making sure life-saving drugs and equipment are available all the time, and posting standard treatment and management protocols in the maternity and emergency rooms will play a vital role in reducing the occurrence of SMO in Keren Hospital.

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

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

Maternal mortality study in the Eastern Democratic Republic of the Congo

Background

The reduction of maternal mortality in developing countries such as the Democratic Republic of Congo (DRC) still raises many questions. Indeed, this large country in the heart of Africa ranks 4th among the eight countries that alone account for more than 50% of maternal deaths in the world, behind India, Nigeria and Pakistan. However, there is no up-to-date data on maternal mortality in eastern DRC. This study measures the mortality rate rate in health facilities in eastern DRC and identifies the associated risk factors.

Methods

This analytical epidemiological study was based on retrospective data materna deaths recorded in 59 health facilities, in three health zones in the southern part of Maniema province in east DRC. The study was conducted from July 1, 2015 to June 30, 2020. Descriptive, bi and multivariate analyses were used.

Results

The maternal mortality rate was estimated at 620 deaths per 100,000 live births, of which 46% of maternal deaths were related to a parturients’ delayed decision in seeking healthcare in time (first delay). Maternal deaths were significantly associated with extreme ages (≤ 19 years and ≥ 40 years: p =  < 0.001), patient parity (in primigravidas and in large multiparas: p = 0.001), complications such as hemorrhagic, (p =  < 0.001), uterine ruptures:(p =  < 0.001), infections, (p =  < 0.001), and dystocia (p =  < 0.001).

Conclusion

Despite the efforts made by the DRC and its partners in the fight against maternal mortality, women continue to lose their lives when they decide to give birth. The results imply that it is imperative to strengthen both women and health professionals’ knowledge about pregnancy and maternal health and their power to reduce instances of first delay by supporting women in formulating their birth plans.