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Chirwa MD, Nyasulu J, Modiba L, Limando MG. Challenges faced by midwives in the implementation of facility-based maternal death reviews in Malawi. BMC Pregnancy Childbirth 2023; 23:282. [PMID: 37095456 PMCID: PMC10124038 DOI: 10.1186/s12884-023-05536-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 10/14/2022] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Maternal death reviews provide an in-depth understanding of the causes of maternal deaths. Midwives are well positioned to contribute to these reviews. Despite midwives' participation as members of the facility-based maternal death review team, maternal mortality continues to occur, therefore, this study aimed to explore the challenges faced by midwives as they participate in maternal death reviews in the context of the healthcare system in Malawi. METHODS This was a qualitative exploratory study design. Focus group discussions and individual face-to-face interviews were used to collect data in the study. A total of 40 midwives, who met the inclusion criteria, participated in the study. Data was analyzed manually using a thematic content procedure. RESULTS Challenges identified were: knowledge and skill gaps; lack of leadership and accountability; lack of institutional political will and inconsistency in conducting FBMDR, impeding midwives' effective contribution to the implementation of maternal death review. The possible solutions and recommendations that emerged were need-based knowledge and skills updates, supportive leadership, effective and efficient interdisciplinary work ethics, and sustained availability of material and human resources. CONCLUSION Midwives have the highest potential to contribute to the reduction of maternal deaths. Practice development strategies are required to improve their practice in all the areas they are challenged with.
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Affiliation(s)
- Mercy Dokiso Chirwa
- Department of Health Studies, University of South Africa, Preller Street, Po Box 392, Pretoria, 0003, South Africa.
| | - Juliet Nyasulu
- Division of Health Systems and Public Health, Department of Global Health, Stellenbosch. University, Cape Town, South Africa
| | - Lebitsi Modiba
- Department of Health Studies, University of South Africa, Preller Street, Po Box 392, Pretoria, 0003, South Africa
| | - Makombo Ganga- Limando
- Department of Health Studies, University of South Africa, Preller Street, Po Box 392, Pretoria, 0003, South Africa
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2
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Willcox ML, Okello IA, Maidwell-Smith A, Tura AK, van den Akker T, Knight M. Maternal and perinatal death surveillance and response: a systematic review of qualitative studies. Bull World Health Organ 2023; 101:62-75G. [PMID: 36593778 PMCID: PMC9795385 DOI: 10.2471/blt.22.288703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 01/04/2023] Open
Abstract
Objective To understand the experiences and perceptions of people implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries, and the mechanisms by which this process can achieve its intended outcomes. Methods In June 2022, we systematically searched seven databases for qualitative studies of stakeholders implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries. Two reviewers independently screened articles and assessed their quality. We used thematic synthesis to derive descriptive themes and a realist approach to understand the context-mechanism-outcome configurations. Findings Fifty-nine studies met the inclusion criteria. Good outcomes (improved quality of care or reduced mortality) were underpinned by a functional action cycle. Mechanisms for effective death surveillance and response included learning, vigilance and implementation of recommendations which motivated further engagement. The key context to enable effective death surveillance and response was a blame-free learning environment with good leadership. Inadequate outcomes (lack of improvement in care and mortality and discontinuation of death surveillance and response) resulted from a vicious cycle of under-reporting, inaccurate data, and inadequate review and recommendations, which led to demotivation and disengagement. Some harmful outcomes were reported, such as inappropriate referrals and worsened staff shortages, which resulted from a fear of negative consequences, including blame, disciplinary action or litigation. Conclusion Conditions needed for effective maternal and/or perinatal death surveillance and response include: separation of the process from litigation and disciplinary procedures; comprehensive guidelines and training; adequate resources to implement recommendations; and supportive supervision to enable safe learning.
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Affiliation(s)
- Merlin L Willcox
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SouthamptonSO16 5SE, England
| | - Immaculate A Okello
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SouthamptonSO16 5SE, England
| | - Alice Maidwell-Smith
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SouthamptonSO16 5SE, England
| | - Abera K Tura
- School of Nursing and Midwifery, Haramaya University, Harar, Ethiopia
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, England
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3
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Nguyen NT, Ding K, Oke R, Tanjong MMS, Mbuh L, Mbianyor MA, Carvalho M, Dissak Delon FN, Boeck M, Collins C, Yenshu EV, Etoundi GA, Juillard C, Mefire AC. Evaluating Shifts in Perception After a Pilot Trauma Quality Improvement Training Course in Cameroon. J Surg Res 2022; 276:151-159. [PMID: 35344741 DOI: 10.1016/j.jss.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/14/2021] [Accepted: 02/14/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Trauma is a major contributor to the global burden of disease, with low- and middle-income countries (LMICs) being disproportionately affected. Trauma Quality Improvement (QI) initiatives could potentially save an estimated two million lives each year. Successful trauma QI initiatives rely on adequate training and a culture of quality among hospital staff. This study evaluated the effect of a pilot trauma QI training course on participants' perceptions on leadership, medical errors, and the QI process in Cameroon. METHODS Study participants took part in a three-day, eight-module course training on trauma QI methods and applications. Perceptions on leadership, medical errors, and QI were assessed pre and post-course using a 15-item survey measured on a five-point Likert scale. Median pre- and post-course scores were compared using the Wilcoxon signed-rank test. Knowledge retention and course satisfaction were also evaluated in a post-course survey and evaluation. RESULTS A majority of the 25 course participants completed pre-course (92%) and post-course (80%) surveys. Participants' perceptions of safety and comfort discussing medical errors at work significantly increased post-course (pre-median = 5, IQR [4-5]; post-median = 5, IQR [5-5]; P = 0.046). The belief that individuals responsible for medical error should be held accountable significantly decreased after the course (pre-median = 3, IQR [2-4]; post-median = 1, IQR [1-2]; P < 0.001). Overall satisfaction with the course was high with median scores ≥4. CONCLUSIONS These initial results suggest that targeted trauma QI training effectively influences attitudes about QI. Further investigation of the effect of the trauma QI training on hospital staff in larger courses is warranted to assess reproducibility of these findings.
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Affiliation(s)
- Nicole T Nguyen
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Kevin Ding
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Rasheedat Oke
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Mary-Magdalene S Tanjong
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Lidwine Mbuh
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Mbiarikai A Mbianyor
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Melissa Carvalho
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | | | - Marissa Boeck
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Caitlin Collins
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Emmanuel V Yenshu
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| | | | - Catherine Juillard
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California.
| | - Alain Chichom Mefire
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
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4
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Mizerero SA, Wilunda C, Musumari PM, Ono-Kihara M, Mubungu G, Kihara M, Nakayama T. The status of emergency obstetric and newborn care in post-conflict eastern DRC: a facility-level cross-sectional study. Confl Health 2021; 15:61. [PMID: 34380531 PMCID: PMC8356431 DOI: 10.1186/s13031-021-00395-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 07/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background Pregnancy-related mortality remains persistently higher in post-conflict areas. Part of the blame lies with continued disruption to vital care provision, especially emergency obstetric and newborn care (EmONC). In such settings, assessment of EmONC is essential for data-driven interventions needed to reduce preventable maternal and neonatal mortality. In the North Kivu Province (NKP), the epicentre of armed conflict in eastern Democratic Republic of the Congo (DRC) between 2006 and 2013, the post-conflict status of EmONC is unknown. We assessed the availability, use, and quality of EmONC in 3 health zones (HZs) of the NKP to contribute to informed policy and programming in improving maternal and newborn health (MNH) in the region. Method A cross-sectional survey of all 42 public facilities designated to provide EmONC in 3 purposively selected HZs in the NKP (Goma, Karisimbi, and Rutshuru) was conducted in 2017. Interviews, reviews of maternity ward records, and observations were used to assess the accessibility, use, and quality of EmONC against WHO standards. Results Only three referral facilities (two faith-based facilities in Goma and the MSF-supported referral hospital of Rutshuru) met the criteria for comprehensive EmONC. None of the health centres qualified as basic EmONC, nor could they offer EmONC services 24 h, 7 days a week (24/7). The number of functioning EmONC per 500,000 population was 1.5. Assisted vaginal delivery was the least performed signal function, followed by parenteral administration of anticonvulsants, mainly due to policy restrictions and lack of demand. The 3 HZs fell short of WHO standards for the use and quality of EmONC. The met need for EmONC was very low and the direct obstetric case fatality rate exceeded the maximum acceptable level. However, the proportion the proportion of births by caesarean section in EmONC facilities was within acceptable range in the HZs of Goma and Rutshuru. Overall, the intrapartum and very early neonatal death rate was 1.5%. Conclusion This study provides grounds for the development of coordinated and evidence-based programming, involving local and external stakeholders, as part of the post-conflict effort to address maternal and neonatal morbidity and mortality in the NKP. Particular attention to basic EmONC is required, focusing on strengthening human resources, equipment, supply chains, and referral capacity, on the one hand, and on tackling residual insecurity that might hinder 24/7 staff availability, on the other.
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Affiliation(s)
- Serge-André Mizerero
- Graduate School of Medicine, School of Public Health, Department of Health Informatics, Kyoto University, Kyoto, Japan.
| | - Calistus Wilunda
- African Population and Health Research Centre, Manga Close, P.O. Box 10787-00100, Nairobi, Kenya
| | - Patou Masika Musumari
- Interdisciplinary Unit for Global Health, Centre for the Promotion of Interdisciplinary Education and Research, Kyoto University, Yoshida honmachi, Sakyo-ku, Kyoto, 606-8501, Japan.,International Institute of Socio-Epidemiology, Kitagosho-cho, Sakyo-ku, Kyoto, 606-8336, Japan
| | - Masako Ono-Kihara
- Interdisciplinary Unit for Global Health, Centre for the Promotion of Interdisciplinary Education and Research, Kyoto University, Yoshida honmachi, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Gerrye Mubungu
- Department of Paediatrics, University Hospital of Kinshasa, School of Medicine, Kinshasa, Democratic Republic of the Congo
| | - Masahiro Kihara
- Interdisciplinary Unit for Global Health, Centre for the Promotion of Interdisciplinary Education and Research, Kyoto University, Yoshida honmachi, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Takeo Nakayama
- Graduate School of Medicine, School of Public Health, Department of Health Informatics, Kyoto University, Kyoto, Japan
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5
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Kinney MV, Ajayi G, de Graft-Johnson J, Hill K, Khadka N, Om’Iniabohs A, Mukora-Mutseyekwa F, Tayebwa E, Shittu O, Lipingu C, Kerber K, Nyakina JD, Ibekwe PC, Sayinzoga F, Madzima B, George AS, Thapa K. "It might be a statistic to me, but every death matters.": An assessment of facility-level maternal and perinatal death surveillance and response systems in four sub-Saharan African countries. PLoS One 2020; 15:e0243722. [PMID: 33338039 PMCID: PMC7748147 DOI: 10.1371/journal.pone.0243722] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 11/29/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Maternal and perinatal death surveillance and response (MPDSR) systems aim to understand and address key contributors to maternal and perinatal deaths to prevent future deaths. From 2016-2017, the US Agency for International Development's Maternal and Child Survival Program conducted an assessment of MPDSR implementation in Nigeria, Rwanda, Tanzania, and Zimbabwe. METHODS A cross-sectional, mixed-methods research design was used to assess MPDSR implementation. The study included a desk review, policy mapping, semistructured interviews with 41 subnational stakeholders, observations, and interviews with key informants at 55 purposefully selected facilities. Using a standardised tool with progress markers defined for six stages of implementation, each facility was assigned a score from 0-30. Quantitative and qualitative data were analysed from the 47 facilities with a score above 10 ('evidence of MPDSR practice'). RESULTS The mean calculated MPDSR implementation progress score across 47 facilities was 18.98 out of 30 (range: 11.75-27.38). The team observed variation across the national MPDSR guidelines and tools, and inconsistent implementation of MPDSR at subnational and facility levels. Nearly all facilities had a designated MPDSR coordinator, but varied in their availability and use of standardised forms and the frequency of mortality audit meetings. Few facilities (9%) had mechanisms in place to promote a no-blame environment. Some facilities (44%) could demonstrate evidence that a change occurred due to MPDSR. Factors enabling implementation included clear support from leadership, commitment from staff, and regular occurrence of meetings. Barriers included lack of health worker capacity, limited staff time, and limited staff motivation. CONCLUSION This study was the first to apply a standardised scoring methodology to assess subnational- and facility-level MPDSR implementation progress. Structures and processes for implementing MPDSR existed in all four countries. Many implementation gaps were identified that can inform priorities and future research for strengthening MPDSR in low-capacity settings.
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Affiliation(s)
- Mary V. Kinney
- Save the Children US, Washington, DC, United States of America
- University of the Western Cape, Cape Town, South Africa
| | - Gbaike Ajayi
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
- Jhpiego, Baltimore, Maryland, United States of America
| | - Joseph de Graft-Johnson
- Save the Children US, Washington, DC, United States of America
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
| | - Kathleen Hill
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
- Jhpiego, Baltimore, Maryland, United States of America
| | - Neena Khadka
- Save the Children US, Washington, DC, United States of America
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
| | - Alyssa Om’Iniabohs
- Save the Children US, Washington, DC, United States of America
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
| | | | | | | | | | - Kate Kerber
- Save the Children US, Washington, DC, United States of America
| | | | - Perpetus Chudi Ibekwe
- Maternal and perinatal death surveillance and response, Abakaliki, Ebonyi State, Nigeria
| | - Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Bernard Madzima
- Family Health Directorate, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Kusum Thapa
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
- Jhpiego, Baltimore, Maryland, United States of America
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6
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Tura AK, Aboul-Ela Y, Fage SG, Ahmed SS, Scherjon S, van Roosmalen J, Stekelenburg J, Zwart J, van den Akker T. Introduction of Criterion-Based Audit of Postpartum Hemorrhage in a University Hospital in Eastern Ethiopia: Implementation and Considerations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E9281. [PMID: 33322495 PMCID: PMC7764538 DOI: 10.3390/ijerph17249281] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 01/10/2023]
Abstract
With postpartum hemorrhage (PPH) continuing to be the leading cause of maternal mortality in most low-resource settings, an audit of the quality of care in health facilities is essential. The purpose of this study was to identify areas of substandard care and establish recommendations for the management of PPH in Hiwot Fana Specialized University Hospital, eastern Ethiopia. Using standard criteria (n = 8) adapted to the local hospital setting, we audited 45 women with PPH admitted from August 2018 to March 2019. Four criteria were agreed as being low: IV line-setup (32 women, 71.1%), accurate postpartum vital sign monitoring (23 women, 51.1%), performing typing and cross-matching (22 women, 48.9%), and fluid intake/output chart maintenance (6 women, 13.3%). In only 3 out of 45 women (6.7%), all eight standard criteria were met. Deficiencies in the case of note documentation and clinical monitoring, non-availability of medical resources and blood for transfusion, as well as delays in clinical management were identified. The audit created awareness, resulting in self-reflection of current practice and promoted a sense of responsibility to improve care among hospital staff. Locally appropriate recommendations and an intervention plan based on available resources were formulated.
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Affiliation(s)
- Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, P.O. Box 235 Harar, Ethiopia;
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands;
| | - Yasmin Aboul-Ela
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands; (Y.A.-E.); (J.v.R.); (T.v.d.A.)
| | - Sagni Girma Fage
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, P.O. Box 235 Harar, Ethiopia;
| | - Semir Sultan Ahmed
- Department of Obstetrics and Gynaecology, Hiwot Fana Specialized University Hospital, P.O. Box 235 Harar, Ethiopia;
| | - Sicco Scherjon
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands;
| | - Jos van Roosmalen
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands; (Y.A.-E.); (J.v.R.); (T.v.d.A.)
- Athena Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University Medical Centre Groningen, 9700 AD Groningen, The Netherlands;
- Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, 8934 AD Leeuwarden, The Netherlands
| | - Joost Zwart
- Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, 7416 SE Deventer, The Netherlands;
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands; (Y.A.-E.); (J.v.R.); (T.v.d.A.)
- Athena Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
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Manzi F, Marchant T, Hanson C, Schellenberg J, Mkumbo E, Mlaguzi M, Tancred T. Harnessing the health systems strengthening potential of quality improvement using realist evaluation: an example from southern Tanzania. Health Policy Plan 2020; 35:ii9-ii21. [PMID: 33156943 PMCID: PMC7646731 DOI: 10.1093/heapol/czaa128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 11/13/2022] Open
Abstract
Quality improvement (QI) is a problem-solving approach in which stakeholders identify context-specific problems and create and implement strategies to address these. It is an approach that is increasingly used to support health system strengthening, which is widely promoted in Sub-Saharan Africa. However, few QI initiatives are sustained and implementation is poorly understood. Here, we propose realist evaluation to fill this gap, sharing an example from southern Tanzania. We use realist evaluation to generate insights around the mechanisms driving QI implementation. These insights can be harnessed to maximize capacity strengthening in QI and to support its operationalization, thus contributing to health systems strengthening. Realist evaluation begins by establishing an initial programme theory, which is presented here. We generated this through an elicitation approach, in which multiple sources (theoretical literature, a document review and previous project reports) were collated and analysed retroductively to generate hypotheses about how the QI intervention is expected to produce specific outcomes linked to implementation. These were organized by health systems building blocks to show how each block may be strengthened through QI processes. Our initial programme theory draws from empowerment theory and emphasizes the self-reinforcing nature of QI: the more it is implemented, the more improvements result, further empowering people to use it. We identified that opportunities that support skill- and confidence-strengthening are essential to optimizing QI, and thus, to maximizing health systems strengthening through QI. Realist evaluation can be used to generate rich implementation data for QI, showcasing how it can be supported in ‘real-world’ conditions for health systems strengthening.
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Affiliation(s)
- Fatuma Manzi
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene and Tropical Medicine, UK
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Sweden
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, UK
| | - Elibariki Mkumbo
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Mwanaidi Mlaguzi
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Tara Tancred
- Department of Disease Control, London School of Hygiene and Tropical Medicine, UK
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8
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Kabuya JBB, Mataka A, Chongo G, Kamavu LK, Chola PN, Manyando C, De Brouwere V, Ippolito MM. Impact of maternal death reviews at a rural hospital in Zambia: a mixed methods study. Int J Equity Health 2020; 19:119. [PMID: 32646431 PMCID: PMC7350714 DOI: 10.1186/s12939-020-01185-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
Background Maternal mortality in sub-Saharan Africa remains high despite programmatic efforts to improve maternal health. In 2007, the Zambian Ministry of Health mandated facility-based maternal death review (MDR) programs in line with World Health Organization recommendations. We assessed the impact of an [MDR program] at a district-level hospital in rural Zambia. Methods We conducted a mixed methods convergent study using hospital data on maternal mortality and audit reports of 106 maternal deaths from 2007 to 2011. To evaluate the overall impact of MDR on maternal mortality, we compared baseline (2007) to late (2010–11) post-intervention inpatient maternal mortality indicators. MDR committee reports were coded and dominant themes were extracted in a qualitative analysis. We assessed potential risk factors for maternal mortality in a before-and-after design comparing the periods 2008–09 and 2010–11. Results In-hospital maternal mortality declined from 23 per thousand live births in 2007 to 8 per thousand in 2010–11 (P < 0.01). Maternal case fatality for puerperal sepsis and uterine rupture decreased significantly from 63 and 32% in 2007 to 10 and 9% in 2010–11 (P < 0.01). No significant reduction was seen in case fatality due to postpartum hemorrhage. Qualitative analysis of risk factors for maternal mortality revealed four core themes: standards of practice, health systems, accessibility, and patient factors. Specific risk factors included delayed referral, missed diagnoses, intra-hospital delays in care, low medication inventory, and medical error. We found no statistically significant differences in the prevalence of risk factors between the before-and-after periods. Conclusions Implementation of MDR was accompanied by a significant decrease in maternal mortality with reductions in maternal death from puerperal sepsis and uterine rupture, but not postpartum hemorrhage. Qualitative analysis of audit reports identified several modifiable risk factors within four core areas. Comparisons of potential explanatory factors did not show any differences over time. These results imply that MDR offers a means for hospitals to curtail maternal deaths, except deaths due to postpartum hemorrhage, suggesting additional interventions are needed. Documentation of MDR meetings provides an instrument to guide further quality improvements.
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Affiliation(s)
| | | | | | | | | | - Christine Manyando
- Department of Public Health, Tropical Diseases Research Centre, Ndola, Zambia
| | - Vincent De Brouwere
- Unit of Health Services Organization, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Matthew M Ippolito
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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9
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Willcox ML, Price J, Scott S, Nicholson BD, Stuart B, Roberts NW, Allott H, Mubangizi V, Dumont A, Harnden A. Death audits and reviews for reducing maternal, perinatal and child mortality. Cochrane Database Syst Rev 2020; 3:CD012982. [PMID: 32212268 PMCID: PMC7093891 DOI: 10.1002/14651858.cd012982.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The United Nations' Sustainable Development Goals (SDGs) include reducing the global maternal mortality rate to less than 70 per 100,000 live births and ending preventable deaths of newborns and children under five years of age, in every country, by 2030. Maternal and perinatal death audit and review is widely recommended as an intervention to reduce maternal and perinatal mortality, and to improve quality of care, and could be key to attaining the SDGs. However, there is uncertainty over the most cost-effective way of auditing and reviewing deaths: community-based audit (verbal and social autopsy), facility-based audits (significant event analysis (SEA)) or a combination of both (confidential enquiry). OBJECTIVES To assess the impact and cost-effectiveness of different types of death audits and reviews in reducing maternal, perinatal and child mortality. SEARCH METHODS We searched the following from inception to 16 January 2019: CENTRAL, Ovid MEDLINE, Embase OvidSP, and five other databases. We identified ongoing studies using ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and searched reference lists of included articles. SELECTION CRITERIA Cluster-randomised trials, cluster non-randomised trials, controlled before-and-after studies and interrupted time series studies of any form of death audit or review that involved reviewing individual cases of maternal, perinatal or child deaths, identifying avoidable factors, and making recommendations. To be included in the review, a study needed to report at least one of the following outcomes: perinatal mortality rate; stillbirth rate; neonatal mortality rate; mortality rate in children under five years of age or maternal mortality rate. DATA COLLECTION AND ANALYSIS We used standard Cochrane Effective Practice and Organisation of Care (EPOC) group methodological procedures. Two review authors independently extracted data, assessed risk of bias and assessed the certainty of the evidence using GRADE. We planned to perform a meta-analysis using a random-effects model but included studies were not homogeneous enough to make pooling their results meaningful. MAIN RESULTS We included two cluster-randomised trials. Both introduced death review and audit as part of a multicomponent intervention, and compared this to current care. The QUARITE study (QUAlity of care, RIsk management, and TEchnology) concerned maternal death reviews in hospitals in West Africa, which had very high maternal and perinatal mortality rates. In contrast, the OPERA trial studied perinatal morbidity/mortality conferences (MMCs) in maternity units in France, which already had very low perinatal mortality rates at baseline. The OPERA intervention in France started with an outreach visit to brief obstetricians, midwives and anaesthetists on the national guidelines on morbidity/mortality case management, and was followed by a series of perinatal MMCs. Half of the intervention units were randomised to receive additional support from a clinical psychologist during these meetings. The OPERA intervention may make little or no difference to overall perinatal mortality (low certainty evidence), however we are uncertain about the effect of the intervention on perinatal mortality related to suboptimal care (very low certainty evidence).The intervention probably reduces perinatal morbidity related to suboptimal care (unadjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.40 to 0.95; 165,353 births; moderate-certainty evidence). The effect of the intervention on stillbirth rate, neonatal mortality, mortality rate in children under five years of age, maternal mortality or adverse effects was not reported. The QUARITE intervention in West Africa focused on training leaders of hospital obstetric teams using the ALARM (Advances in Labour And Risk Management) course, which included one day of training about conducting maternal death reviews. The leaders returned to their hospitals, established a multidisciplinary committee and started auditing maternal deaths, with the support of external facilitators. The intervention probably reduces inpatient maternal deaths (adjusted OR 0.85, 95% CI 0.73 to 0.98; 191,167 deliveries; moderate certainty evidence) and probably also reduces inpatient neonatal mortality within 24 hours following birth (adjusted OR 0.74, 95% CI 0.61 to 0.90; moderate certainty evidence). However, QUARITE probably makes little or no difference to the inpatient stillbirth rate (moderate certainty evidence) and may make little or no difference to the inpatient neonatal mortality rate after 24 hours, although the 95% confidence interval includes both benefit and harm (low certainty evidence). The QUARITE intervention probably increases the percent of women receiving high quality of care (OR 1.87, 95% CI 1.35 - 2.57, moderate-certainty evidence). The effect of the intervention on perinatal mortality, mortality rate in children under five years of age, or adverse effects was not reported. We did not find any studies that evaluated child death audit and review or community-based death reviews or costs. AUTHORS' CONCLUSIONS A complex intervention including maternal death audit and review, as well as development of local leadership and training, probably reduces inpatient maternal mortality in low-income country district hospitals, and probably slightly improves quality of care. Perinatal death audit and review, as part of a complex intervention with training, probably improves quality of care, as measured by perinatal morbidity related to suboptimal care, in a high-income setting where mortality was already very low. The WHO recommends that maternal and perinatal death reviews should be conducted in all hospitals globally. However, conducting death reviews in isolation may not be sufficient to achieve the reductions in mortality observed in the QUARITE trial. This review suggests that maternal death audit and review may need to be implemented as part of an intervention package which also includes elements such as training of a leading doctor and midwife in each hospital, annual recertification, and quarterly outreach visits by external facilitators to provide supervision and mentorship. The same may also apply to perinatal and child death reviews. More operational research is needed on the most cost-effective ways of implementing maternal, perinatal and paediatric death reviews in low- and middle-income countries.
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Affiliation(s)
- Merlin L Willcox
- University of Southampton, Aldermoor Health CentreDepartment of Primary Care and Population SciencesAldermoor CloseSouthamptonHampshireUKSO16 5ST
| | - Jessica Price
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Sophie Scott
- University of Southampton, Aldermoor Health CentreDepartment of Primary Care and Population SciencesAldermoor CloseSouthamptonHampshireUKSO16 5ST
| | - Brian D Nicholson
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Beth Stuart
- University of SouthamptonPrimary Care and Population Sciences, Faculty of MedicineSouthamptonUKSO16 5ST
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Helen Allott
- Liverpool School of Tropical MedicineCentre for Maternal and Newborn HealthPembroke PlLiverpoolUKL3 5QA
| | - Vincent Mubangizi
- Mbarara University of Science and Technology (MUST)Family medicine and community practiceMUST, PLOT 10‐18, KABALE ROADMbararaUganda1410, Mbarara
| | - Alexandre Dumont
- Institut de recherche pour le développement, Paris Descartes UniversityUMR 196 CEPEDFaculté de Pharmacie, 4 avenue de l?ObservatoireParisFrance75006
| | - Anthony Harnden
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
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Strengthening and monitoring health system's capacity to improve availability, utilization and quality of emergency obstetric care in northern Nigeria. PLoS One 2019; 14:e0211858. [PMID: 30726275 PMCID: PMC6364938 DOI: 10.1371/journal.pone.0211858] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 01/23/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Quality improvement in emergency obstetric care (EmOC) is a critical and cost-effective suite of interventions for the reduction of maternal and newborn mortality and morbidity. This study was undertaken to evaluate the impact of quality improvement interventions following a baseline assessment in Bauchi state, Nigeria. METHODS This was a prospective before and after study between June 2012, and April 2015 in Bauchi State, Nigeria. The surveys included 21 hospitals designated by Ministry of Health (MoH) as comprehensive EmOC centers and 38 primary healthcare centers (PHCs) designated as basic EmOC centers. Data on EmOC services was collected using structured established EmOC tools developed by the Averting Maternal Death and Disability (AMDD), and analyzed using univariate and bivariate statistical analyses. RESULTS Facilities providing seven or nine signal EmOC functions increased from 6 (10.2%) in 2012 to 21 (35.6%) in 2015. Basic EmOC facilities increased from 1 (2.6%) to 7 (18.4%) and comprehensive EmOC facilities rose from 3 (14.3%) to 13 (61.9%). Facility birth increased from 3.6% to 8.0%. Cesarean birth rates increased from 3.8% in 2012 to 5.6% in 2015. Met need for EmOC more than doubled from 3.3% in 2012 to 9.9% in 2015. Direct obstetric case fatality rates increased from 3.1% in 2012 to 4.0% in 2015. Major direct obstetric complications as a percent of total maternal deaths was 70.9%, down from 80.1% in 2012. CONCLUSION The rise in the percent of facility-based births and in met need for EmOC suggest that interventions recommended and implemented after the baseline study resulted in increased availability, access and utilization of EmOC. Higher patient load, late arrival and better record keeping may explain the associated increase in case fatality rates.
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Chen I, Opiyo N, Tavender E, Mortazhejri S, Rader T, Petkovic J, Yogasingam S, Taljaard M, Agarwal S, Laopaiboon M, Wasiak J, Khunpradit S, Lumbiganon P, Gruen RL, Betran AP. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev 2018; 9:CD005528. [PMID: 30264405 PMCID: PMC6513634 DOI: 10.1002/14651858.cd005528.pub3] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline. OBJECTIVES To evaluate the effectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures recommended by Cochrane. We narratively described results of individual studies (drawing summarised evidence from single studies assessing distinct interventions). MAIN RESULTS We included 29 studies in this review (19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies). Most of the studies (20 studies) were conducted in high-income countries and none took place in low-income countries. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.Overall, we found low-, moderate- or high-certainty evidence that the following interventions have a beneficial effect on at least one primary outcome measure and no moderate- or high-certainty evidence of adverse effects.Interventions targeted at women or familiesChildbirth training workshops for mothers alone may reduce caesarean section (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.33 to 0.89) and may increase spontaneous vaginal birth (RR 2.25, 95% CI 1.16 to 4.36). Childbirth training workshops for couples may reduce caesarean section (RR 0.59, 95% CI 0.37 to 0.94) and may increase spontaneous vaginal birth (RR 2.13, 95% CI 1.09 to 4.16). We judged this one study with 60 participants to have low-certainty evidence for the outcomes above.Nurse-led applied relaxation training programmes (RR 0.22, 95% CI 0.11 to 0.43; 104 participants, low-certainty evidence) and psychosocial couple-based prevention programmes (RR 0.53, 95% CI 0.32 to 0.90; 147 participants, low-certainty evidence) may reduce caesarean section. Psychoeducation may increase spontaneous vaginal birth (RR 1.33, 95% CI 1.11 to 1.61; 371 participants, low-certainty evidence). The control group received routine maternity care in all studies.There were insufficient data on the effect of the four interventions on maternal and neonatal mortality or morbidity.Interventions targeted at healthcare professionalsImplementation of clinical practice guidelines combined with mandatory second opinion for caesarean section indication slightly reduces the risk of overall caesarean section (mean difference in rate change -1.9%, 95% CI -3.8 to -0.1; 149,223 participants). Implementation of clinical practice guidelines combined with audit and feedback also slightly reduces the risk of caesarean section (risk difference (RD) -1.8%, 95% CI -3.8 to -0.2; 105,351 participants). Physician education by local opinion leader (obstetrician-gynaecologist) reduced the risk of elective caesarean section to 53.7% from 66.8% (opinion leader education: 53.7%, 95% CI 46.5 to 61.0%; control: 66.8%, 95% CI 61.7 to 72.0%; 2496 participants). Healthcare professionals in the control groups received routine care in the studies. There was little or no difference in maternal and neonatal mortality or morbidity between study groups. We judged the certainty of evidence to be high.Interventions targeted at healthcare organisations or facilitiesCollaborative midwifery-labourist care (in which the obstetrician provides in-house labour and delivery coverage, 24 hours a day, without competing clinical duties), versus a private practice model of care, may reduce the primary caesarean section rate. In one interrupted time series study, the caesarean section rate decreased by 7% in the year after the intervention, and by 1.7% per year thereafter (1722 participants); the vaginal birth rate after caesarean section increased from 13.3% before to 22.4% after the intervention (684 participants). Maternal and neonatal mortality were not reported. We judged the certainty of evidence to be low.We studied the following interventions, and they either made little or no difference to caesarean section rates or had uncertain effects.Moderate-certainty evidence suggests little or no difference in caesarean section rates between usual care and: antenatal education programmes for physiologic childbirth; antenatal education on natural childbirth preparation with training in breathing and relaxation techniques; computer-based decision aids; individualised prenatal education and support programmes (versus written information in pamphlet).Low-certainty evidence suggests little or no difference in caesarean section rates between usual care and: psychoeducation; pelvic floor muscle training exercises with telephone follow-up (versus pelvic floor muscle training without telephone follow-up); intensive group therapy (cognitive behavioural therapy and childbirth psychotherapy); education of public health nurses on childbirth classes; role play (versus standard education using lectures); interactive decision aids (versus educational brochures); labourist model of obstetric care (versus traditional model of obstetric care).We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low. AUTHORS' CONCLUSIONS We evaluated a wide range of non-clinical interventions to reduce unnecessary caesarean section, mostly in high-income settings. Few interventions with moderate- or high-certainty evidence, mainly targeting healthcare professionals (implementation of guidelines combined with mandatory second opinion, implementation of guidelines combined with audit and feedback, physician education by local opinion leader) have been shown to safely reduce caesarean section rates. There are uncertainties in existing evidence related to very-low or low-certainty evidence, applicability of interventions and lack of studies, particularly around interventions targeted at women or families and healthcare organisations or facilities.
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Affiliation(s)
- Innie Chen
- University of OttawaDepartment of Obstetrics & GynecologyOttawaONCanada
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Emma Tavender
- Monash UniversityAustralian Satellite of the Cochrane EPOC Group, School of Public Health and Preventative MedicineMelbourneVictoriaAustraliaVIC 3004
| | | | - Tamara Rader
- Canadian Agency for Drugs and Technologies in Health (CADTH)600‐865 Carling AvenueOttawaONCanada
| | - Jennifer Petkovic
- University of OttawaBruyère Research Institute43 Bruyère StAnnex E, room 312OttawaONCanadaK1N 5C8
| | | | - Monica Taljaard
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ Civic Campus1053 Carling Ave, Box 693OttawaONCanadaK1Y 4E9
| | | | - Malinee Laopaiboon
- Khon Kaen UniversityDepartment of Epidemiology and Biostatistics, Faculty of Public Health123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Jason Wasiak
- Austin Health; The University of MelbourneOlivia Newton John Cancer Research Institute; Department of PaediatricsMelbourneVictoriaAustralia
- University of MelbourneDepartment of PediatricsMelbourneVictoriaAustralia
| | - Suthit Khunpradit
- Lamphun HospitalDepartment of Obstetrics and Gynaecology177 Jamthevee RoadLamphunLamphunThailand51000
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Russell L Gruen
- Nanyang Technological UniversityLee Kong Chian School of Medicine11 Mandalay RoadSingaporeSingapore308232
| | - Ana Pilar Betran
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and ResearchGenevaSwitzerland
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Lazzerini M, Richardson S, Ciardelli V, Erenbourg A. Effectiveness of the facility-based maternal near-miss case reviews in improving maternal and newborn quality of care in low-income and middle-income countries: a systematic review. BMJ Open 2018; 8:e019787. [PMID: 29674368 PMCID: PMC5914892 DOI: 10.1136/bmjopen-2017-019787] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/01/2018] [Accepted: 02/20/2018] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES The maternal near-miss case review (NMCR) has been promoted by WHO as an approach to improve quality of care (QoC) at facility level. This systematic review synthesises evidence on the effectiveness of the NMCR on QoC and maternal and perinatal health outcomes in low-income and middle-income countries (LMICs). METHODS Studies were searched for in six electronic databases (MEDLINE, Index Medicus, Web of Science, the Cochrane library, Embase, LILACS), with no language restrictions. Two authors independently screened papers and selected them for inclusion and independently extracted data. Maternal mortality was the primary outcome. Secondary outcomes included any outcome informing on any of the six dimensions of QoC: efficacy, safety, efficiency, equity, accessibility and timely care, acceptability and patient-centred care. RESULTS Out of 24 822 papers retrieved, 17 studies from 11 countries were included. Maternal mortality measured before and after the implementation of the NMCR cycle significantly decreased (OR 0.77, 95% CI 0.61 to 0.98, eight studies, 55 573 043 women; I2=39%). A statistically significant reduction in the incidence of uterine rupture, postpartum haemorrhage and maternal sepsis was observed in three out of six studies. Ten studies reporting on maternal care process all showed some significant improvement when measured against predefined standards. All studies reported that the NMCR resulted in some amelioration of the facility structure (physical structure, staffing, equipment, training, organisation of care). Newborn outcomes were overall poorly reported; four studies showed no significant difference in perinatal mortality. Patient satisfaction and equity were also poorly reported. CONCLUSIONS Policy makers may consider implementing the maternal NMCR cycle approach among strategies aiming at improving QoC and reducing maternal mortality and morbidity in LMIC. Future studies should better document the effectiveness of the NMCR cycle particularly on outcomes reflecting patient-centred care and cost-effectiveness.
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Affiliation(s)
- Marzia Lazzerini
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Sonia Richardson
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Valentina Ciardelli
- Department of Obstetrics and Gynaecology, Bentivoglio Hospital, Bentivoglio, Italy
| | - Anna Erenbourg
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
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Bacci A, Hodorogea S, Khachatryan H, Babojonova S, Irsa S, Jansone M, Dondiuc I, Matarazde G, Lazdane G, Lazzerini M. What is the quality of the maternal near-miss case reviews in WHO European Region? Cross-sectional study in Armenia, Georgia, Latvia, Republic of Moldova and Uzbekistan. BMJ Open 2018; 8:e017696. [PMID: 29654004 PMCID: PMC5898291 DOI: 10.1136/bmjopen-2017-017696] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 12/12/2017] [Accepted: 12/14/2017] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES The maternal near-miss case review (NMCR) cycle is a type of clinical audit aiming at improving quality of maternal healthcare by discussing near-miss cases. In several countries this approach has been introduced and supported by WHO and partners since 2004, but information on the quality of its implementation is missing. This study aimed at evaluating the quality of the NMCR implementation in selected countries within WHO European Region. DESIGN Cross-sectional study. SETTINGS Twenty-three maternity units in Armenia, Georgia, Latvia, Moldova and Uzbekistan. ASSESSMENT TOOLS A predefined checklist including 50 items, according to WHO methodology. Quality in the NMCR implementation was defined by summary scores ranging from 0 (totally inappropriate) to 3 (appropriate). RESULTS Quality of the NMCR implementation was heterogeneous among different countries, and within the same country. Overall, the first part of the audit cycle (from case identification to case analysis) was fairly well performed (mean score 2.00, 95% CI 1.94 to 2.06), with the exception of the 'inclusion of users' views' (mean score 0.66, 95% CI 0.11 to 1.22), while the second part (developing recommendations, implementing them and ensuring quality) was poorly performed (mean score 0.66, 95% CI 0.11 to 1.22). Each country had at least one champion facility, where quality of the NMCR cycle was acceptable. Quality of the implementation was not associated with its duration. Gaps in implementation were of technical, organisational and attitudinal nature. CONCLUSIONS Ensuring quality in the NMCR may be difficult but achievable. The high heterogeneity in results within the same country suggests that quality of the NMCR implementation depends, to a large extent, from hospital factors, including staff's commitment, managerial support and local coordination. Efforts should be put in preventing and mitigating common barriers that hamper successful NMCR implementation.
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Affiliation(s)
- Alberta Bacci
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Stelian Hodorogea
- State Medical and Pharmaceutical University "N. Testemitanu", Chisinau, Moldova
| | | | | | - Signe Irsa
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | | | | | - Gunta Lazdane
- Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Marzia Lazzerini
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
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Smith H, Ameh C, Roos N, Mathai M, Broek NVD. Implementing maternal death surveillance and response: a review of lessons from country case studies. BMC Pregnancy Childbirth 2017; 17:233. [PMID: 28716124 PMCID: PMC5513145 DOI: 10.1186/s12884-017-1405-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 07/03/2017] [Indexed: 11/10/2022] Open
Abstract
Background Maternal Death Surveillance and Response (MDSR) implementation is monitored globally, but not much is known about what works well, where and why in scaling up. We reviewed a series of country case studies in order to determine whether and to what extent these countries have implemented the four essential components of MDSR and identify lessons for improving implementation. Methods A secondary analysis of ten case studies from countries at different stages of MDSR implementation, using a policy analysis framework to draw out lessons learnt and opportunities for improvement. We identify the consistent drivers of success in countries with well-established systems for MDSR, and common barriers in countries were Maternal Death Review (MDR) systems have been less successful. Results MDR is accepted and ongoing at subnational level in many countries, but it is not adequately institutionalised and the shift from facility based MDR to continuous MDSR that informs the wider health system still needs to be made. Our secondary analysis of country experiences highlights the need for a) social and team processes at facility level, for example the existence of a ‘no shame, no blame’ culture, and the ability to reflect on practice and manage change as a team for recommendations to be acted upon, b) health system inputs including adequate funding and reliable health information systems to enable identification and analysis of cases c) national level coordination of dissemination, and monitoring implementation of recommendations at all levels and d) mandatory notification of maternal deaths (and enforcement of this) and a professional requirement to participate in MDRs. Conclusions Case studies from countries with established MDSR systems can provide valuable guidance on ways to set up the processes and overcome some of the barriers; but the challenge, as with many health system interventions, is to find a way to provide catalytic assistance and strengthen capacity for MDSR such that this becomes embedded in the health system.
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Affiliation(s)
- Helen Smith
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Charles Ameh
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Natalie Roos
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Matthews Mathai
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Mawarti Y, Utarini A, Hakimi M. Maternal care quality in near miss and maternal mortality in an academic public tertiary hospital in Yogyakarta, Indonesia: a retrospective cohort study. BMC Pregnancy Childbirth 2017; 17:149. [PMID: 28532393 PMCID: PMC5440944 DOI: 10.1186/s12884-017-1326-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 05/08/2017] [Indexed: 11/21/2022] Open
Abstract
Background Reducing maternal mortality remains a major challenge for health care systems worldwide. The factors related to maternal mortality were extensively researched, and maternal death clusters around labour, delivery and the immediate postpartum period. Studies on the quality of maternal care in academic medical centre settings in low income countries are uncommon. Methods A retrospective cohort study of maternal deaths was conducted in an academic public tertiary hospital in Yogyakarta, and maternal near misses were used as controls. Data were obtained from medical records from February 1, 2011 to September 30, 2012. Three groups of variables were measured: (1) timeliness of care, (2) adherence to a standard of process indicators, and (3) associated extraneous variables. Variables were analysed using logistic regression to explore their effects on maternal mortality. Results The mean of triage response time and obstetric resident response time were longer in maternal deaths (8 ± 3.59 and 36.17 ± 23.48 min respectively) compared to near misses (1.29 ± 0.24 and 18.78 ± 4.85 min respectively). Near misses more frequently received oxytocin treatment than the maternal deaths (OR 0.13; 95%CI 0.02–0.77). Magnesium sulfate treatment in severe-preeclampsia or eclampsia was less given in maternal deaths although insignificant statistically (OR 0.19; 95% CI 0.03–1.47). Prophylactic antibiotic was also more frequently given in near misses than in maternal deaths though insignificant statistically (OR 0.3; 95% CI 0.06–1.56). Extraneous variables, such as caesarean sections were less performed in maternal deaths (OR 0.15; 95% CI 0.04–0.51), vaginal deliveries were more frequent in maternal deaths (OR 3.47; 95% CI 1.05–11.54), and more women in near misses were referred from other health care facilities (OR 0.09; 95% CI 0.01–0.91). Conclusions The near misses had relatively received better quality of care compared to the maternal deaths. The near misses had received faster response time and better treatments. Timely referral systems enabled benefits to prevent maternal death.
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Affiliation(s)
- Yuli Mawarti
- Public Health Graduate Program, Faculty of Medicine, Universitas Gadjah Mada, Sekip, Yogyakarta, 55281, Indonesia.
| | - Adi Utarini
- Department of Public Health, Faculty of Medicine, Universitas Gadjah Mada, Sekip, Yogyakarta, 55281, Indonesia
| | - Mohammad Hakimi
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Gadjah Mada, Sekip, Yogyakarta, 55281, Indonesia
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Dossa NI, Philibert A, Dumont A. Using routine health data and intermittent community surveys to assess the impact of maternal and neonatal health interventions in low-income countries: A systematic review. Int J Gynaecol Obstet 2017; 135 Suppl 1:S64-S71. [PMID: 27836087 DOI: 10.1016/j.ijgo.2016.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is a need to provide increased evidence on effective interventions to reduce maternal and neonatal mortality in low- and middle-income countries (LMICs). OBJECTIVES To summarize the breadth of knowledge on using routine data (Routine Health Information Systems [RHIS] and Intermittent Community Surveys [ICS]) for well-designed maternal and neonatal health evaluations in LMICs. SEARCH STRATEGY We searched reports and articles published in Embase, Medline, and Google scholar. Selection criteria Studies were considered for inclusion if they were carried out in LMICs, using RHIS or ICS data with experimental or quasi-experimental design. DATA COLLECTION AND ANALYSIS A form was used to collect information on indicators used for interventions' impact assessment. Descriptive statistics and multiple correspondence analyses were then performed. MAIN RESULTS Of the 1201 publications identified, 46 studies met the inclusion criteria. Most of these were using RHIS data (n=40), mainly extracted from health facility registers (n=34), and non-controlled before and after design (n=30). The indicators, which were mostly reported, were related to the use of healthcare services (n=36) and maternal/neonatal health outcomes (n=31). Few studies used ICS data (n=6) or indicators of severity (n=2). CONCLUSION RHIS and ICS data should be increasingly used for impact studies on maternal and neonatal health in LMICs.
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Affiliation(s)
- Nissou I Dossa
- Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
| | - Aline Philibert
- Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Interdisciplinary Research Centre on Well-being, Health, Society and Environment (CINBIOSE), Université du Québec à Montréal, Canada
| | - Alexandre Dumont
- Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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Martin Hilber A, Blake C, Bohle LF, Bandali S, Agbon E, Hulton L. Strengthening accountability for improved maternal and newborn health: A mapping of studies in Sub-Saharan Africa. Int J Gynaecol Obstet 2016; 135:345-357. [PMID: 27802869 DOI: 10.1016/j.ijgo.2016.09.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To describe the types of maternal and newborn health program accountability mechanisms implemented and evaluated in recent years in Sub-Saharan Africa, how these have been implemented, their effectiveness, and future prospects to improve governance and MNH outcomes. METHOD A structured review selected 38 peer-reviewed papers between 2006 and 2016 in Sub-Saharan Africa to include in the analysis. RESULTS Performance accountability in MNH through maternal and perinatal death surveillance was the most common accountability mechanism used. Political and democratic accountability through advocacy, human rights, and global tracking of progress on indicators achieved greatest results when multiple stakeholders were involved. Financial accountability can be effective but depend on external support. Overall, this review shows that accountability is more effective when clear expectations are backed by social and political advocacy and multistakeholder engagement, and supported by incentives for positive action. CONCLUSION There are few accountability mechanisms in MNH in Sub-Saharan Africa between decision-makers and those affected by those decisions with both the power and the will to enforce answerability. Increasing accountability depends not only on how mechanisms are enforced but also, on how providers and managers understand accountability.
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Affiliation(s)
- Adriane Martin Hilber
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | - Carolyn Blake
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Leah F Bohle
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Sarah Bandali
- Evidence for Action, Options Consultancy Services Ltd, London, UK
| | - Esther Agbon
- Evidence for Action, Options Consultancy Services Ltd, Abuja, Nigeria
| | - Louise Hulton
- Evidence for Action, Options Consultancy Services Ltd, London, UK
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Wekesah FM, Mbada CE, Muula AS, Kabiru CW, Muthuri SK, Izugbara CO. Effective non-drug interventions for improving outcomes and quality of maternal health care in sub-Saharan Africa: a systematic review. Syst Rev 2016; 5:137. [PMID: 27526773 PMCID: PMC4986260 DOI: 10.1186/s13643-016-0305-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 06/20/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Many interventions have been implemented to improve maternal health outcomes in sub-Saharan Africa (SSA). Currently, however, systematic information on the effectiveness of these interventions remains scarce. We conducted a systematic review of published evidence on non-drug interventions that reported effectiveness in improving outcomes and quality of care in maternal health in SSA. METHODS African Journals Online, Bioline, MEDLINE, Ovid, Science Direct, and Scopus databases were searched for studies published in English between 2000 and 2015 and reporting on the effectiveness of interventions to improve quality and outcomes of maternal health care in SSA. Articles focusing on interventions that involved drug treatments, medications, or therapies were excluded. We present a narrative synthesis of the reported impact of these interventions on maternal morbidity and mortality outcomes as well as on other dimensions of the quality of maternal health care (as defined by the Institute of Medicine 2001 to comprise safety, effectiveness, efficiency, timeliness, patient centeredness, and equitability). RESULTS Seventy-three studies were included in this review. Non-drug interventions that directly or indirectly improved quality of maternal health and morbidity and mortality outcomes in SSA assumed a variety of forms including mobile and electronic health, financial incentives on the demand and supply side, facility-based clinical audits and maternal death reviews, health systems strengthening interventions, community mobilization and/or peer-based programs, home-based visits, counseling and health educational and promotional programs conducted by health care providers, transportation and/or communication and referrals for emergency obstetric care, prevention of mother-to-child transmission of HIV, and task shifting interventions. There was a preponderance of single facility and community-based studies whose effectiveness was difficult to assess. CONCLUSIONS Many non-drug interventions have been implemented to improve maternal health care in SSA. These interventions have largely been health facility and/or community based. While the evidence on the effectiveness of interventions to improve maternal health is varied, study findings underscore the importance of implementing comprehensive interventions that strengthen different components of the health care systems, both in the community and at the health facilities, coupled with a supportive policy environment. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015023750.
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Affiliation(s)
- Frederick M. Wekesah
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
- Julius Global Health, Julius Center for Health Sciences and Primary Care, Utrecht Medical Center, Utrecht Huispost Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, Netherlands
| | - Chidozie E. Mbada
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
- Department of Medical Rehabilitation, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Adamson S. Muula
- Department of Public Health, School of Public Health and Family Health, College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre, Malawi
- African Center for Public Health and Herbal Medicine, University of Malawi, Blantyre, Malawi
| | - Caroline W. Kabiru
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| | - Stella K. Muthuri
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| | - Chimaraoke O. Izugbara
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
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Brenner S, De Allegri M, Gabrysch S, Chinkhumba J, Sarker M, Muula AS. The quality of clinical maternal and neonatal healthcare - a strategy for identifying 'routine care signal functions'. PLoS One 2015; 10:e0123968. [PMID: 25875252 PMCID: PMC4398438 DOI: 10.1371/journal.pone.0123968] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 02/17/2015] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND A variety of clinical process indicators exists to measure the quality of care provided by maternal and neonatal health (MNH) programs. To allow comparison across MNH programs in low- and middle-income countries (LMICs), a core set of essential process indicators is needed. Although such a core set is available for emergency obstetric care (EmOC), the 'EmOC signal functions', a similar approach is currently missing for MNH routine care evaluation. We describe a strategy for identifying core process indicators for routine care and illustrate their usefulness in a field example. METHODS We first developed an indicator selection strategy by combining epidemiological and programmatic aspects relevant to MNH in LMICs. We then identified routine care process indicators meeting our selection criteria by reviewing existing quality of care assessment protocols. We grouped these indicators into three categories based on their main function in addressing risk factors of maternal or neonatal complications. We then tested this indicator set in a study assessing MNH quality of clinical care in 33 health facilities in Malawi. RESULTS Our strategy identified 51 routine care processes: 23 related to initial patient risk assessment, 17 to risk monitoring, 11 to risk prevention. During the clinical performance assessment a total of 82 cases were observed. Birth attendants' adherence to clinical standards was lowest in relation to risk monitoring processes. In relation to major complications, routine care processes addressing fetal and newborn distress were performed relatively consistently, but there were major gaps in the performance of routine care processes addressing bleeding, infection, and pre-eclampsia risks. CONCLUSION The identified set of process indicators could identify major gaps in the quality of obstetric and neonatal care provided during the intra- and immediate postpartum period. We hope our suggested indicators for essential routine care processes will contribute to streamlining MNH program evaluations in LMICs.
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Affiliation(s)
- Stephan Brenner
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Manuela De Allegri
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Sabine Gabrysch
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Jobiba Chinkhumba
- Department of Community Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Malabika Sarker
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Adamson S. Muula
- Department of Community Health, University of Malawi, College of Medicine, Blantyre, Malawi
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Zongo A, Dumont A, Fournier P, Traore M, Kouanda S, Sondo B. Effect of maternal death reviews and training on maternal mortality among cesarean delivery: post-hoc analysis of a cluster-randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2015; 185:174-80. [DOI: 10.1016/j.ejogrb.2014.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 12/17/2014] [Accepted: 12/23/2014] [Indexed: 11/28/2022]
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Okeke T, Ekwuazi K. Is there Still a Place for Vacuum Extraction (Ventouse) in Modern Obstetric Practice in Nigeria. Ann Med Health Sci Res 2014; 3:471-4. [PMID: 24379994 PMCID: PMC3868109 DOI: 10.4103/2141-9248.122043] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
There has been a decline in operative vaginal delivery world-wide. Vacuum extraction has largely replaced forceps delivery in our low resource setting and in the developed countries, but the teaching and exposure of this procedure is still on the decline. There is a need for enhanced teaching and exposure of operative vaginal delivery and mastering of the procedure in our centers by the residents in training. Review of the pertinent literature and studies on operative vaginal delivery, selected references, internet services on operative vaginal delivery. Earlier studies on operative vaginal delivery showed that vacuum extraction has been the procedure of choice. The rates reported from developed countries were much higher than the rates reported from Nigeria. Vacuum extraction rates of 1.5% from Zaria, 1.7% from Maiduguri, 1.6% from Ilorin and 3.5% from Benin City all in Nigeria. At the University of Nigeria Teaching Hospital, Enugu-Nigeria, ventouse is popular with rates of 3.1% in 1980, 3.5% in 2001, and 1.5% in 2006, but still on the decline. Vacuum extraction is safe and effective practice in our poor resource setting. There is a need for enhanced teaching and exposure of residents in training because widely divergent situation can exist; facilities and adequate back up for caesarean section may not always be available in our poor resource setting.
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Affiliation(s)
- Tc Okeke
- Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Ke Ekwuazi
- Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria
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Combs Thorsen V, Sundby J, Meguid T, Malata A. Easier said than done!: methodological challenges with conducting maternal death review research in Malawi. BMC Med Res Methodol 2014; 14:29. [PMID: 24559148 PMCID: PMC3946085 DOI: 10.1186/1471-2288-14-29] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 02/10/2014] [Indexed: 11/20/2022] Open
Abstract
Background Maternal death auditing is widely used to ascertain in-depth information on the clinical, social, cultural, and other contributing factors that result in a maternal death. As the 2015 deadline for Millennium Development Goal 5 of reducing maternal mortality by three quarters between 1990 and 2015 draws near, this information becomes even more critical for informing intensified maternal mortality reduction strategies. Studies using maternal death audit methodologies are widely available, but few discuss the challenges in their implementation. The purpose of this paper is to discuss the methodological issues that arose while conducting maternal death review research in Lilongwe, Malawi. Methods Critical reflections were based on a recently conducted maternal mortality study in Lilongwe, Malawi in which a facility-based maternal death review approach was used. The five-step maternal mortality surveillance cycle provided the framework for discussion. The steps included: 1) identification of cases, 2) data collection, 3) data analysis, 4) recommendations, and 5) evaluation. Results Challenges experienced were related to the first three steps of the surveillance cycle. They included: 1) identification of cases: conflicting maternal death numbers, and missing medical charts, 2) data collection: poor record keeping, poor quality of documentation, difficulties in identifying and locating appropriate healthcare workers for interviews, the potential introduction of bias through the use of an interpreter, and difficulties with locating family and community members and recall bias; and 3) data analysis: determining the causes of death and clinical diagnoses. Conclusion Conducting facility-based maternal death reviews for the purpose of research has several challenges. This paper illustrated that performing such an activity, particularly the data collection phase, was not as easy as conveyed in international guidelines and in published studies. However, these challenges are not insurmountable. If they are anticipated and proper steps are taken in advance, they can be avoided or their effects minimized.
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Affiliation(s)
- Viva Combs Thorsen
- Department of Community Medicine, University of Oslo, PO Box 1130, Blindern, N-0318 Oslo, Norway.
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Montoya A, Calvert C, Filippi V. Explaining differences in maternal mortality levels in sub-Saharan African hospitals: a systematic review and meta-analysis. Int Health 2014; 6:12-22. [DOI: 10.1093/inthealth/iht037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Dettrick Z, Firth S, Jimenez Soto E. Do strategies to improve quality of maternal and child health care in lower and middle income countries lead to improved outcomes? A review of the evidence. PLoS One 2013; 8:e83070. [PMID: 24349435 PMCID: PMC3857295 DOI: 10.1371/journal.pone.0083070] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 11/07/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Efforts to scale-up maternal and child health services in lower and middle income countries will fail if services delivered are not of good quality. Although there is evidence of strategies to increase the quality of health services, less is known about the way these strategies affect health system goals and outcomes. We conducted a systematic review of the literature to examine this relationship. METHODS We undertook a search of MEDLINE, SCOPUS and CINAHL databases, limiting the results to studies including strategies specifically aimed at improving quality that also reported a measure of quality and at least one indicator related to health system outcomes. Variation in study methodologies prevented further quantitative analysis; instead we present a narrative review of the evidence. FINDINGS Methodologically, the quality of evidence was poor, and dominated by studies of individual facilities. Studies relied heavily on service utilisation as a measure of strategy success, which did not always correspond to improved quality. The majority of studies targeted the competency of staff and adequacy of facilities. No strategies addressed distribution systems, public-private partnership or equity. Key themes identified were the conflict between perceptions of patients and clinical measures of quality and the need for holistic approaches to health system interventions. CONCLUSION Existing evidence linking quality improvement strategies to improved MNCH outcomes is extremely limited. Future research would benefit from the inclusion of more appropriate indicators and additional focus on non-facility determinants of health service quality such as health policy, supply distribution, community acceptability and equity of care.
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Affiliation(s)
- Zoe Dettrick
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
- * E-mail:
| | - Sonja Firth
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
| | - Eliana Jimenez Soto
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
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Dumont A, Fournier P, Abrahamowicz M, Traoré M, Haddad S, Fraser WD. Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial. Lancet 2013; 382:146-57. [PMID: 23721752 DOI: 10.1016/s0140-6736(13)60593-0] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Maternal mortality is higher in west Africa than in most industrialised countries, so the development and validation of effective interventions is essential. We did a trial to assess the effect of a multifaceted intervention to promote maternity death reviews and onsite training in emergency obstetric care in referral hospitals with high maternal mortality rates in Senegal and Mali. METHODS We did a pragmatic cluster-randomised controlled trial, with hospitals as the units of randomisation and patients as the unit of analysis. 46 public first-level and second-level referral hospitals with more than 800 deliveries a year were enrolled, stratified by country and hospital type, and randomly assigned to either the intervention group (n=23) or the control group with no external intervention (n=23). All women who delivered in each of the participating facilities during the baseline and post-intervention periods were included. The intervention, implemented over a period of 2 years at the hospital level, consisted of an initial interactive workshop and quarterly educational clinically-oriented and evidence-based outreach visits focused on maternal death reviews and best practices implementation. The primary outcome was reduction of risk of hospital-based mortality. Analysis was by intention-to-treat and relied on the generalised estimating equations extension of the logistic regression model to account for clustering of women within hospitals. This study is registered with ClinicalTrials.gov, number ISRCTN46950658. FINDINGS 191,167 patients who delivered in the participating hospitals were analysed (95,931 in the intervention groups and 95,236 in the control groups). Overall, mortality reduction in intervention hospitals was significantly higher than in control hospitals (odds ratio [OR] 0·85, 95% CI 0·73-0·98, p=0·0299), but this effect was limited to capital and district hospitals, which mainly acted as first-level referral hospitals in this trial. There was no effect in second-level referral (regional) hospitals outside the capitals (OR 1·02, 95% CI 0·79-1·31, p=0·89). No hospitals were lost to follow-up. Concrete actions were implemented comprehensively to improve quality of care in intervention hospitals. INTERPRETATION Regular visits by a trained external facilitator and onsite training can provide health-care professionals with the knowledge and confidence to make quality improvement suggestions during audit sessions. Maternal death reviews, combined with best practices implementation, are effective in reducing hospital-based mortality in first-level referral hospitals. Further studies are needed to determine whether the benefits of the intervention are generalisable to second-level referral hospitals. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Alexandre Dumont
- Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France.
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Mony PK, Krishnamurthy J, Thomas A, Sankar K, Ramesh BM, Moses S, Blanchard J, Avery L. Availability and distribution of emergency obstetric care services in Karnataka State, South India: access and equity considerations. PLoS One 2013; 8:e64126. [PMID: 23717547 PMCID: PMC3661461 DOI: 10.1371/journal.pone.0064126] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 04/10/2013] [Indexed: 12/02/2022] Open
Abstract
Background As part of efforts to reduce maternal deaths in Karnataka state, India, there has been a concerted effort to increase institutional deliveries. However, little is known about the quality of care in these healthcare facilities. We investigated the availability and distribution of emergency obstetric care (EmOC) services in eight northern districts of Karnataka state in south India. Methods & Findings We undertook a cross-sectional study of 444 government and 422 private health facilities, functional 24-hours-a-day 7-days-a-week. EmOC availability and distribution were evaluated for 8 districts and 42 taluks (sub-districts) during the year 2010, based on a combination of self-reporting, record review and direct observation. Overall, the availability of EmOC services at the sub-state level [EmOC = 5.9/500,000; comprehensive EmOC (CEmOC) = 4.5/500,000 and basic EmOC (BEmOC) = 1.4/500,000] was seen to meet the benchmark. These services however were largely located in the private sector (90% of CEmOC and 70% of BemOC facilities). Thirty six percent of private facilities and six percent of government facilities were EmOC centres. Although half of eight districts had a sufficient number of EmOC facilities and all eight districts had a sufficient number of CEmOC facilities, only two-fifths of the 42 taluks had a sufficient number of EmOC facilities. With the private facilities being largely located in select towns only, the ‘non-headquarter’ taluks and ‘backward’ taluks suffered from a marked lack of coverage of these services. Spatial mapping further helped identify the clustering of a large number of contiguous taluks without adequate government EmOC facilities in northeastern Karnataka. Conclusions In conclusion, disaggregating information on emergency obstetric care service availability at district and subdistrict levels is critical for health policy and planning in the Indian setting. Reducing maternal deaths will require greater attention by the government in addressing inequities in the distribution of emergency obstetric care services.
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Affiliation(s)
- Prem K Mony
- Division of Epidemiology & Population Health, St John's Research Institute, Bangalore, India.
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Dumont A. Comment réduire la mortalité maternelle? BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2012. [DOI: 10.1016/s0001-4079(19)31678-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Maaløe N, Bygbjerg IC, Onesmo R, Secher NJ, Sorensen BL. Disclosing doubtful indications for emergency cesarean sections in rural hospitals in Tanzania: a retrospective criterion-based audit. Acta Obstet Gynecol Scand 2012; 91:1069-76. [PMID: 22642620 DOI: 10.1111/j.1600-0412.2012.01474.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate in depth to what extent indications for emergency cesarean sections followed evidence-based audit criteria for realistic best practice. DESIGN A quality assurance analysis based on a retrospective criterion-based audit. SETTING Two rural hospitals in Tanzania. POPULATION From 2009, 400 cesarean section instances were investigated. Of these, 303 were emergency cesarean sections and therefore included. METHODS Documented indications for and management preceding the emergency cesarean sections were compared with the audit criteria. MAIN OUTCOME MEASURES Prevalence of suboptimal care. RESULTS Of the emergency sections, 26% appeared to be decided based on inappropriate indications, and in an additional 38%, the indications were unclear. Prolonged labor was the leading indication; in 36% of these, labor progressed timely and/or the membranes were still intact. In 26%, previous cesarean section was the indication, half of these with one previous section only. Fetal distress was an indication in 14%, but for 84% of these the fetal heart rate was either reassuring or not documented. For nine women, section was decided upon because of intrauterine fetal death; none had a trial of forceps/vacuum extraction or destructive surgery. CONCLUSION A considerable number of the audited emergency cesarean sections were performed on doubtful indications. In the light of the rising trend in global cesarean section rates, there seems to be a need to ensure quality of management preceding cesarean sections. This is particularly called for in rural sub-Saharan Africa where cesarean rates are still low and health risks of emergency surgery not negligible.
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Affiliation(s)
- Nanna Maaløe
- Department of International Health, Immunology, and Microbiology, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, Denmark.
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Koşum Z, Yurdakul M. Factors affecting the use of emergency obstetric care among pregnant women with antenatal bleeding. Midwifery 2012; 29:440-6. [PMID: 22652487 DOI: 10.1016/j.midw.2012.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2011] [Revised: 12/31/2011] [Accepted: 02/27/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE to investigate the factors that affect the use of emergency obstetric care services among pregnant women in Turkey with antenatal bleeding. DESIGN descriptive, cross-sectional study. SETTING Mersin Maternity and Child Hospital, Mersin, Turkey. PARTICIPANTS 125 pregnant women who had been admitted to the emergency department for antenatal bleeding. FINDINGS advanced age, high level of education, lack of health insurance, receiving antenatal care, nuclear family structure and knowledge of the danger signs during pregnancy were found to affect the use of emergency obstetric care services among pregnant women with antenatal bleeding. KEY CONCLUSIONS delays in seeking emergency obstetric care among pregnant women with antenatal bleeding are due to the difficulties faced by women when deciding whether or not to seek health care. Access to health services and health institutions themselves do not cause any delay in terms of provision of emergency obstetric care to pregnant women with antenatal bleeding. IMPLICATIONS FOR PRACTICE pregnant women should be informed about the causes of antenatal bleeding, what to do in the case of bleeding, and the need to seek health care as soon as possible. In addition, midwives should inform families and pregnant women about the use of emergency medical services and the relevant procedures.
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Affiliation(s)
- Zübeyde Koşum
- Mersin Provincial Health Directorate, 112 Emergency Medical Services Unit, Mersin, Turkey
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Maaløe N, Sorensen BL, Onesmo R, Secher NJ, Bygbjerg IC. Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals. BJOG 2012; 119:605-13. [PMID: 22329559 DOI: 10.1111/j.1471-0528.2012.03284.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- N Maaløe
- Department of International Health, Immunology, and Microbiology, University of Copenhagen, Copenhagen, Denmark.
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Raven JH, Tolhurst RJ, Tang S, van den Broek N. What is quality in maternal and neonatal health care? Midwifery 2011; 28:e676-83. [PMID: 22018395 DOI: 10.1016/j.midw.2011.09.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 08/26/2011] [Accepted: 09/11/2011] [Indexed: 10/16/2022]
Abstract
OBJECTIVE to review published papers and reports examining quality of care in maternal and newborn health to identify definitions and models of quality of care. DESIGN literature review. SEARCH STRATEGY electronic search of MEDLINE and organisational databases for literature describing definitions and models of quality used in health care and maternal and newborn health care. Relevant papers and reports were reviewed and summarised. FINDINGS there is no universally accepted definition of quality of care. The multi-faceted nature of quality is widely acknowledged. In the literature quality of care is described: from the perspective of health care providers, managers and patients; dimensions within the health care system; using elements such as safety, effectiveness, patient-centeredness, timeliness, equity and efficiency; and through the provision of care and experience of care. KEY CONCLUSIONS the importance of ensuring good quality of care for women and newborn babies is well recognised in the literature, however, there is currently no agreed single and comprehensive definition described. Several models were identified, which can be combined to form a comprehensive framework to help define and assess quality of care or lack of quality. Approaches to quality of care that are specifically important for maternal and newborn health were identified and include a rights based approach, adopting care that is evidence-based, consideration of the mother and baby as interdependent and the fact that pregnancy is on the whole a healthy state. IMPLICATIONS FOR PRACTICE a model of quality of maternal and newborn health care using perspectives, characteristics, dimensions of the system and elements of quality of care specific to maternal and newborn health is proposed, which can be used as a basis for developing quality improvement strategies and activities, and incorporating quality into existing programmes.
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Affiliation(s)
- Joanna H Raven
- Maternal and Newborn Health Unit, Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK.
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Raven J, Hofman J, Adegoke A, van den Broek N. Methodology and tools for quality improvement in maternal and newborn health care. Int J Gynaecol Obstet 2011; 114:4-9. [PMID: 21621681 DOI: 10.1016/j.ijgo.2011.02.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 02/16/2011] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To gain an overview of approaches, methodologies, and tools used in quality improvement of maternal and newborn health in low-income countries. METHODS Electronic search of MEDLINE and organizational databases for literature describing approaches, methodologies, and tools used to improve the quality of maternal and newborn health care in low-income countries. Relevant papers and reports were reviewed and summarized. RESULTS Developing a culture of quality is an important requisite for successful quality improvement. Methodologies to improve quality include the development of standards and guidelines and the performance of mortality, near-miss, and criterion-based audits. Tools for data collection and process description were identified, and examples of work to improve quality of care are provided. CONCLUSION The documented experience with the identified approaches, methodologies, and tools indicates that none is sufficient by itself to achieve a desirable improvement in quality of care. The choice of methodologies and tools depends on the healthcare system and its available resources. There is a lack of studies that describe the process of quality improvement and a need for research to provide evidence of the effectiveness of the identified methods and tools.
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Affiliation(s)
- Joanna Raven
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Liverpool, UK.
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Khunpradit S, Tavender E, Lumbiganon P, Laopaiboon M, Wasiak J, Gruen RL. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev 2011:CD005528. [PMID: 21678348 DOI: 10.1002/14651858.cd005528.pub2] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Caesarean section rates are steadily increasing globally. The factors contributing to these observed increases are complex. Non-clinical interventions, those applied independent of patient care in a clinical encounter, may have a role in reducing unnecessary caesarean sections. OBJECTIVES To evaluate the effectiveness and safety of non-clinical interventions for reducing unnecessary caesarean sections. SEARCH STRATEGY We searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (29 March 2010), the Cochrane Pregnancy and Childbirth Group Specialised Register (29 March 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 2); MEDLINE (1950 to March 2010); EMBASE (1947 to March 2010) and CINAHL (1982 to March 2010). SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-experimental studies, controlled clinical trials (CCTs), controlled before and after studies (CBAs) with at least two intervention and control sites, and interrupted time series analyses (ITS) where the intervention time was clearly defined and there were at least three data points before and three after the intervention. Studies evaluated non-clinical interventions to reduce unnecessary caesarean section rates. Participants included pregnant women and their families, healthcare providers who work with expectant mothers, communities and advocacy groups. DATA COLLECTION AND ANALYSIS Three review authors independently assessed the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information. MAIN RESULTS We included 16 studies in this review.Six studies specifically targeted pregnant women. Two RCTs were shown to be effective in reducing caesarean section rates: a nurse-led relaxation training programme for women with a fear or anxiety of childbirth and birth preparation sessions. However, both RCTs were small in size and targeted younger mothers with their first pregnancies. There is insufficient evidence that prenatal education and support programmes, computer patient decision-aids, decision-aid booklets and intensive group therapy are effective.Ten studies targeted health professionals. Three of these studies were effective in reducing caesarean section rates. A cluster-RCT of guideline implementation with mandatory second opinion resulted in a small, statistically significant reduction in total caesarean section rates (adjusted risk difference (RD) -1.9; 95% confidence interval (CI) -3.8 to -0.1); this reduction was predominately in intrapartum sections. An ITS study of mandatory second opinion and peer review feedback at department meetings found statistically significant results at 48 months for reducing repeat caesarean section rates (change in level was -6.4%; 95% CI -9.7% to -3.1% and change in slope -1.14%; 95% CI -1.9% to -0.3%) but not for total caesarean section rates. A cluster-RCT of guideline implementation with support from local opinion leaders increased the proportion of women with a previous caesarean section being offered a trial of labour (absolute difference 16.8%) and the number who had a vaginal birth (VBAC rates) (absolute difference 13.5%). The P values are, however, not reported due to unit of analysis errors. There was insufficient evidence that audit and feedback, training of public health nurses, insurance reform, external peer review and legislative changes are effective. AUTHORS' CONCLUSIONS Implementation of guidelines with mandatory second opinion can lead to a small reduction in caesarean section rates, predominately in intrapartum sections. Peer review, including pre-caesarean consultation, mandatory secondary opinion and postcaesarean surveillance can lead to a reduction in repeat caesarean section rates. Guidelines disseminated with endorsement and support from local opinion leaders may increase the proportion of women with previous caesarean sections being offered a trial of labour in certain settings. Nurse-led relaxation classes and birth preparation classes may reduce caesarean section rates in low-risk pregnancies.
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Affiliation(s)
- Suthit Khunpradit
- Department of Obstetrics and Gynaecology, Lamphun Hospital, 177 Jamthevee Road, Lamphun, Lamphun, Thailand, 51000
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van den Akker T, van Rhenen J, Mwagomba B, Lommerse K, Vinkhumbo S, van Roosmalen J. Reduction of severe acute maternal morbidity and maternal mortality in Thyolo District, Malawi: the impact of obstetric audit. PLoS One 2011; 6:e20776. [PMID: 21677788 PMCID: PMC3109003 DOI: 10.1371/journal.pone.0020776] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 05/11/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Critical incident audit and feedback are recommended interventions to improve the quality of obstetric care. To evaluate the effect of audit at district level in Thyolo, Malawi, we assessed the incidence of facility-based severe maternal complications (severe acute maternal morbidity (SAMM) and maternal mortality) during two years of audit and feedback. METHODOLOGY/PRINCIPAL FINDINGS Between September 2007 and September 2009, we included all cases of maternal mortality and SAMM that occurred in Thyolo District Hospital, the main referral facility in the area, using validated disease-specific criteria. During two- to three-weekly audit sessions, health workers and managers identified substandard care factors. Resulting recommendations were implemented and followed up. Feedback was given during subsequent sessions. A linear regression analysis was performed on facility-based severe maternal complications. During the two-year study period, 386 women were included: 46 died and 340 sustained SAMM, giving a case fatality rate of 11.9%. Forty-five cases out of the 386 inclusions were audited in plenary with hospital staff. There was a reduction of 3.1 women with severe maternal complications per 1000 deliveries in the district health facilities, from 13.5 per 1000 deliveries in the beginning to 10.4 per 1000 deliveries at the end of the study period. The incidence of uterine rupture and major obstetric hemorrhage reduced considerably (from 3.5 to 0.2 and from 5.9 to 2.6 per 1000 facility deliveries respectively). CONCLUSIONS Our findings indicate that audit and feedback have the potential to reduce serious maternal complications including maternal mortality. Complications like major hemorrhage and uterine rupture that require relatively straightforward intrapartum emergency management are easier to reduce than those which require uptake of improved antenatal care (eclampsia) or timely intravenous medication or HIV-treatment (peripartum infections).
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Kongnyuy EJ, Hofman JJ, van den Broek N. Ensuring effective Essential Obstetric Care in resource poor settings. BJOG 2010; 116 Suppl 1:41-7. [PMID: 19740171 DOI: 10.1111/j.1471-0528.2009.02332.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Although Emergency Obstetric Care (EOC) is globally accepted as a key strategy to improve maternal health and reduce maternal mortality, there is still a lot of debate surrounding its use--What is EOC? Is it evidence-based? How can we measure it? How can we improve access to EOC? This paper attempts to answer these questions. Although there are no randomized controlled trials, there is strong evidence from quasi-experimental, observational and ecological studies that EOC should be a critical component of any programme to reduce maternal mortality. This paper also identifies the barriers to accessing EOC and proposes strategies to overcome them which could contribute to achieving Millennium Development Goal 5.
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Affiliation(s)
- E J Kongnyuy
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, UK.
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van den Broek NR, Graham WJ. Quality of care for maternal and newborn health: the neglected agenda. BJOG 2010; 116 Suppl 1:18-21. [PMID: 19740165 DOI: 10.1111/j.1471-0528.2009.02333.x] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The quality of care received by mothers and babies in developing countries is often reported as poor. Yet efforts to address this contributory factor to maternal and newborn mortality have received less attention compared with barriers of access to care. The current heightened concern to achieve Millennium Development Goals 4 & 5 has illuminated the neglected quality agenda. Whilst there is no universally-accepted definition of "quality care", it is widely acknowledged to embrace multiple levels--from patient to health system, and multiple dimensions, including safety as well as efficiency. Quality care should thus lie at the core of all strategies for accelerating progress towards MDG4 &5. Interventions to measure and improve quality need themselves to be evidence-based. Two promising approaches are maternal and perinatal death reviews and criterion-based audit. These and other quality improvement tools have a crucial role to play in the implementation of effective maternal and newborn care.
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Affiliation(s)
- N R van den Broek
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Liverpool, UK.
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