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Sequeira Dmello B, John TW, Housseine N, Meyrowitsch DW, van Roosmalen J, van den Akker T, Kujabi ML, Festo C, Nkungu D, Muniro Z, Kabanda I, Msumi R, Maembe L, Sangalala M, Hyera E, Lema J, Bayongo S, Mshiu J, Kidanto HL, Maaløe N. Incidence and determinants of perinatal mortality in five urban hospitals in Dar es Salaam, Tanzania: a cohort study with an embedded case-control analysis. BMC Pregnancy Childbirth 2024; 24:62. [PMID: 38218766 PMCID: PMC10787400 DOI: 10.1186/s12884-023-06096-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 10/30/2023] [Indexed: 01/15/2024] Open
Abstract
INTRODUCTION Tanzania has one of the highest burdens of perinatal mortality, with a higher risk among urban versus rural women. To understand the characteristics of perinatal mortality in urban health facilities, study objectives were: I. To assess the incidence of perinatal deaths in public health facilities in Dar es Salaam and classify these into a) pre-facility stillbirths (absence of fetal heart tones on admission to the study health facilities) and b) intra-facility perinatal deaths before discharge; and II. To identify determinants of perinatal deaths by comparing each of the two groups of perinatal deaths with healthy newborns. METHODS This was a retrospective cohort study among women who gave birth in five urban, public health facilities in Dar es Salaam. I. Incidence of perinatal death in the year 2020 was calculated based on routinely collected health facility records and the Perinatal Problem Identification Database. II. An embedded case-control study was conducted within a sub-population of singletons with birthweight ≥ 2000 g (excluding newborns with congenital malformations); pre-facility stillbirths and intra-facility perinatal deaths were compared with 'healthy newborns' (Apgar score ≥ 8 at one and ≥ 9 at five minutes and discharged home alive). Descriptive and logistic regression analyses were performed to explore the determinants of deaths. RESULTS A total of 37,787 births were recorded in 2020. The pre-discharge perinatal death rate was 38.3 per 1,000 total births: a stillbirth rate of 27.7 per 1,000 total births and an intra-facility neonatal death rate of 10.9 per 1,000 live births. Pre-facility stillbirths accounted for 88.4% of the stillbirths. The case-control study included 2,224 women (452 pre-facility stillbirths; 287 intra-facility perinatal deaths and 1,485 controls), 99% of whom attended antenatal clinic (75% with more than three visits). Pre-facility stillbirths were associated with low birth weight (cOR 4.40; (95% CI: 3.13-6.18) and with maternal hypertension (cOR 4.72; 95% CI: 3.30-6.76). Intra-facility perinatal deaths were associated with breech presentation (aOR 40.3; 95% CI: 8.75-185.61), complications in the second stage (aOR 20.04; 95% CI: 12.02-33.41), low birth weight (aOR 5.57; 95% CI: 2.62-11.84), cervical dilation crossing the partograph's action line (aOR 4.16; 95% CI:2.29-7.56), and hypertension during intrapartum care (aOR 2.9; 95% CI 1.03-8.14), among other factors. CONCLUSION: The perinatal death rate in the five urban hospitals was linked to gaps in the quality of antenatal and intrapartum care, in the study health facilities and in lower-level referral clinics. Urgent action is required to implement context-specific interventions and conduct implementation research to strengthen the urban referral system across the entire continuum of care from pregnancy onset to postpartum. The role of hypertensive disorders in pregnancy as a crucial determinant of perinatal deaths emphasizes the complexities of maternal-perinatal health within urban settings.
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Affiliation(s)
- Brenda Sequeira Dmello
- Comprehensive Community Based Rehabilitation in Tanzania (CCBRT), P. O Box 23310, Dar Es Salaam, Tanzania.
- Medical College, East Africa, Aga Khan University, Dar es Salaam, Tanzania.
- Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark.
| | - Thomas Wiswa John
- Medical College, East Africa, Aga Khan University, Dar es Salaam, Tanzania
- Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark
| | - Natasha Housseine
- Medical College, East Africa, Aga Khan University, Dar es Salaam, Tanzania
- Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark
| | - Dan Wolf Meyrowitsch
- Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark
| | - Jos van Roosmalen
- Athena Institute, VU University, Amsterdam, the Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas van den Akker
- Athena Institute, VU University, Amsterdam, the Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monica Lauridsen Kujabi
- Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark
| | | | - Daniel Nkungu
- Regional Referral Hospital Dar Es Salaam, Ministry of Health, Dar es Salaam, Tanzania
| | - Zainab Muniro
- Regional Referral Hospital Dar Es Salaam, Ministry of Health, Dar es Salaam, Tanzania
| | - Idrissa Kabanda
- Presidents Office, Regional and Local Government, Municipal Maternity Hospitals Ubungo and Temeke, Dar es Salaam, Tanzania
| | - Rukia Msumi
- Presidents Office, Regional and Local Government, Municipal Maternity Hospitals Ubungo and Temeke, Dar es Salaam, Tanzania
| | - Luzango Maembe
- Regional Referral Hospital Dar Es Salaam, Ministry of Health, Dar es Salaam, Tanzania
| | - Mtingele Sangalala
- Regional Referral Hospital Dar Es Salaam, Ministry of Health, Dar es Salaam, Tanzania
| | - Ester Hyera
- Regional Referral Hospital Dar Es Salaam, Ministry of Health, Dar es Salaam, Tanzania
| | - Joyce Lema
- Presidents Office, Regional and Local Government, Municipal Maternity Hospitals Ubungo and Temeke, Dar es Salaam, Tanzania
| | - Scolastica Bayongo
- Regional Referral Hospital Dar Es Salaam, Ministry of Health, Dar es Salaam, Tanzania
| | - Johnson Mshiu
- Muhimbili Medical Research Center, National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | - Nanna Maaløe
- Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics and Gynecology, Copenhagen University Hospital - Herlev Hospital, Herlev, Denmark
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Maaløe N, Andersen CB, Housseine N, Meguid T, Bygbjerg IC, van Roosmalen J. Effect of locally tailored clinical guidelines on intrapartum management of severe hypertensive disorders at Zanzibar's tertiary hospital (the PartoMa study). Int J Gynaecol Obstet 2018; 144:27-36. [PMID: 30307609 PMCID: PMC7379925 DOI: 10.1002/ijgo.12692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 07/19/2018] [Accepted: 10/08/2018] [Indexed: 11/30/2022]
Abstract
Objective To estimate the effect of locally tailored clinical guidelines on intrapartum care and perinatal outcomes among women with severe hypertensive disorders in pregnancy (sHDP). Methods A pre–post study at Zanzibar's low‐resource Mnazi Mmoja Hospital was conducted. All labouring women with sHDP were included at baseline (October 2014 to January 2015) and at 9–12 months after implementation of the ongoing intervention (October 2015 to January 2016). Background characteristics, clinical practice, and delivery outcomes were assessed by criterion‐based case file reviews. Results Overall, 188 of 2761 (6.8%) women had sHDP at baseline, and 196 of 2398 (8.2%) did so during the intervention months. The median time between last blood pressure recording and delivery decreased during the intervention compared with baseline (P=0.015). Among women with severe hypertension, antihypertensive treatment increased during the intervention compared with baseline (relative risk [RR] 1.37, 95% confidence interval [CI] 1.14–1.66). Among the neonates delivered (birthweight ≥1000 g), stillbirths decreased (RR 0.56, 95% CI 0.35–0.90) and Apgar scores of seven or more increased during the intervention compared with baseline (RR 1.17, 95% CI 1.03–1.33). Conclusion Although health system strengthening remains crucial, locally tailored clinical guidelines seemed to help work‐overloaded birth attendants at a low‐resource hospital to improve care for women with sHDP. ClinicalTrials.org NCT02318420. Among women with severe hypertensive disorders at Zanzibar's referral hospital, locally tailored intrapartum guidelines were associated with care improvements and 44% risk reduction of stillbirth.
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Camilla B Andersen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Natasha Housseine
- Mnazi Mmoja Hospital, Zanzibar City, Tanzania.,Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, Netherlands
| | - Tarek Meguid
- Mnazi Mmoja Hospital, Zanzibar City, Tanzania.,O'Neill Institute for National and Global Health Law, Georgetown University, Washington, DC, USA
| | - Ib C Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jos van Roosmalen
- Athena Institute, VU University of Amsterdam, Amsterdam, Netherlands
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Maaløe N, Housseine N, Meguid T, Nielsen BB, Jensen A, Khamis RS, Mohamed AG, Ali MM, Said SM, van Roosmalen J, Bygbjerg IC. Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of Zanzibar: a quasi-experimental pre-post study (The PartoMa study). BJOG 2017; 125:235-245. [PMID: 28892306 DOI: 10.1111/1471-0528.14933] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia. DESIGN Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice. SETTING Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital. POPULATION Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention
month (1 October 2015 until 31 January 2016) [corrected]. METHODS Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively). MAIN OUTCOME MEASURES Stillbirths and neonates with 5-minute Apgar score ≤5. RESULTS Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53-0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41-0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60-240) to 74 minutes (IQR 30-130) (Mann-Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37-0.81) and timely use improved. CONCLUSION Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. TWEETABLE ABSTRACT: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital PLAIN LANGUAGE SUMMARY: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th-12th month of use. Such a 'before-after' study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines.
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Affiliation(s)
- N Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - N Housseine
- Mnazi Mmoja Hospital, Zanzibar, Tanzania.,Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - T Meguid
- Mnazi Mmoja Hospital, Zanzibar, Tanzania.,School of Health & Medical Sciences, State University of Zanzibar, Zanzibar, Tanzania
| | - B B Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Akg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - R S Khamis
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | | | - M M Ali
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - S M Said
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - J van Roosmalen
- Athena Institute, VU University of Amsterdam, Amsterdam, the Netherlands
| | - I C Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Maaløe N, Housseine N, van Roosmalen J, Bygbjerg IC, Tersbøl BP, Khamis RS, Nielsen BB, Meguid T. Labour management guidelines for a Tanzanian referral hospital: The participatory development process and birth attendants' perceptions. BMC Pregnancy Childbirth 2017; 17:175. [PMID: 28592237 PMCID: PMC5463375 DOI: 10.1186/s12884-017-1360-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While international guidelines for intrapartum care appear to have increased rapidly since 2000, literature suggests that it has only in few instances been matched with reviews of local modifications, use, and impact at the targeted low resource facilities. At a Tanzanian referral hospital, this paper describes the development process of locally achievable, partograph-associated, and peer-reviewed labour management guidelines, and it presents an assessment of professional birth attendants' perceptions. METHODS Part 1: Modification of evidence-based international guidelines through repeated evaluation cycles by local staff and seven external specialists in midwifery/obstetrics. Part 2: Questionnaire evaluation 12 months post-implementation of perceptions and use among professional birth attendants. RESULTS Part 1: After the development process, including three rounds of evaluation by staff and two external peer-review cycles, there were no major concerns with the guidelines internally nor externally. Thereby, international recommendations were condensed to the eight-paged 'PartoMa guidelines ©'. This pocket booklet includes routine assessments, supportive care, and management of common abnormalities in foetal heart rate, labour progress, and maternal condition. It uses colour codes indicating urgency. Compared to international guidelines, reductions were made in frequency of assessments, information load, and ambiguity. Part 2: Response rate of 84% (n = 84). The majority of staff (93%) agreed that the guidelines helped to improve care. They found the guidelines achievable (89%), and the graphics worked well (90%). Doctors more often than nurse-midwives (89% versus 74%) responded to use the guidelines daily. CONCLUSIONS The PartoMa guidelines ensure readily available, locally achievable, and acceptable support for intrapartum surveillance, triage, and management. This is a crucial example of adapting evidence-based international recommendations to local reality. TRIAL REGISTRATION This paper describes the intervention of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Natasha Housseine
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Jos van Roosmalen
- Athena Institute, VU University of Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, the Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Rashid Saleh Khamis
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - Birgitte Bruun Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 København Ø, Denmark
| | - Tarek Meguid
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
- School of Health & Medical Sciences, State University of Zanzibar, P.O.Box:146, Zanzibar, Tanzania
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Maaløe N, Housseine N, Bygbjerg IC, Meguid T, Khamis RS, Mohamed AG, Nielsen BB, van Roosmalen J. Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study. BMC Pregnancy Childbirth 2016; 16:351. [PMID: 27832753 PMCID: PMC5103376 DOI: 10.1186/s12884-016-1142-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/01/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital. METHODS A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249). RESULTS The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital's registers. The majority of singletons had birthweight ≥2000 g (n = 139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75-315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06-3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68-5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70-12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect. CONCLUSIONS Intrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities. TRIAL REGISTRATION This is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Natasha Housseine
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Tarek Meguid
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
- School of Health & Medical Sciences, State University of Zanzibar, P.O.Box:146, Zanzibar, Tanzania
| | | | | | - Birgitte Bruun Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Jos van Roosmalen
- Athena Institute, VU University of Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands
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