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

Geographic inequalities, and social-demographic determinants of reproductive, maternal and child health at sub-national levels in Kenya

BACKGROUND

Global initiatives have emphasized tracking indicators to monitor progress, particularly in countries with the highest maternal and child mortality. Routine data can be used to monitor indicators for improved target setting at national and subnational levels. Our objective was to assess the geographic inequalities in estimates of reproductive, maternal and child health indicators from routine data at the subnational level in Kenya.

METHODS

Monthly data from 47 counties clustered in 8 regions, from January 2018 to December 2021 were assembled from the District Health Information Software version 2 (DHIS2) in Kenya. This included women of reproductive age receiving family planning commodities, pregnant women completing four antenatal care visits, deliveries conducted by skilled birth attendants, fully immunized children at 1 year and number of maternal deaths at health facilities, from which five indicators were constructed with denominators. A hierarchical Bayesian model was used to generate estimates of the five indicators at the at sub-national levels(counties and sub counties), adjusting for four determinants of health. A reproductive, maternal, and child health (RMCH) index was generated from the 5 indicators to compare overall performance across the continuum of care in reproductive, maternal and child health across the different counties.

RESULTS

The DHIS2 data quality for the selected 5 indicators was acceptable with detection of less than 3% outliers for the Facility Maternal Mortality Ratio (FMMR) and less than 1% for the other indicators. Overall, counties in the north-eastern, eastern and coastal regions had the lowest RMCH index due to low service coverage and high FMMR. Full immunization coverage at 1 year (FIC) had the highest estimate (79.3%, BCI: 77.8-80.5%), while Women of Reproductive age receiving FP commodities had the lowest estimate (38.6%, BCI: 38.2-38.9%). FMMR was estimated at 105.4, (BCI 67.3-177.1)Health facility density was an important determinant in estimating all five indicators. Maternal education was positively correlated with higher FIC coverage, while wealthier sub counties had higher FMMR.

CONCLUSIONS

Tracking of RMCH indicators revealed geographical inequalities at the County and subcounty level, often masked by national-level estimates. These findings underscore the value of routine monitoring indicators as a potential for evidence-based sub-national planning and precision targeting of interventions to marginalized populations.

Predictors of institutional delivery service utilization in Ethiopia: an umbrella review

INTRODUCTION

One of the global health's top priorities is improving maternal health. There is a high maternal mortality ratio, despite its major progress in the past two decades. Many countries in Sub-Saharan Africa, including Ethiopia, have not yet reached the sustainable development goal target. The majority of women die of labor and delivery-related complications, which are preventable if they had access to maternal health service utilization, particularly institutional delivery services. The low institutional delivery services utilization in Ethiopia was related to several factors. There are literature disagreements on these predictors and systematic review and meta-analysis (SRMA) studies reported different contributing factors. Therefore, this umbrella review aimed to identify pooled predictors of institutional delivery service utilization in Ethiopia.

METHOD

PubMed, Web of Science, Embase, CINAHL, Scopus, Google Scholar and Cochrane were searched for SRMA studies on the predictors of institutional delivery service utilization in Ethiopia. All SRMA studies selected for potential inclusion in the umbrella review were subjected to a rigorous, independent appraisal by two critical reviewers using the Assessment of Multiple Systematic Reviews tool. Authors selected SRMA studies and abstracted data independently, and discrepancies were resolved through discussion or a third author intervened. A random-effects meta-analysis model was used to pool estimates of the included SRMA studies. Studies' heterogeneity and risk of bias were assessed using I2 and Egger tests, respectively.

RESULT

The umbrella review revealed that institutional delivery services utilization in Ethiopia was 24% (95% confidence interval, CI: 14 to 34). Further, women education (odds ratio, OR = 3.54, 95% CI: 3.04, 4.12), attitude of the women toward maternal and child health (MCH) service (OR = 2.20, 95% CI: 1.30, 3.74), place of residence (OR = 3.29, 95% CI: 2.02, 5.34), live less than 5 km away from the nearest health facilities (OR = 3.48, 95% CI: 2.58, 4.71) and having at least one antenatal care follow-up (OR = 3.62, 95% CI: 3.03, 4.33) were significantly associated with institutional delivery service utilization.

CONCLUSION

The proportion of pregnant women using institutional delivery services is low in Ethiopia. The findings highlight women's education, tailored intervention in the attitude of women toward maternal and child health services, supporting rural communities, improving access and availability of health facilities and promoting antenatal care (ANC) follow-up play a crucial role in enhancing facility childbirth, thereby reducing maternal and neonatal mortality and achieving sustainable development goal 3.1 and 3.2.

"Where and Whom You Collect Weightings from Matters…" Capturing Wellbeing Priorities Within a Vulnerable Context: A Case Study of Volta Delta, Ghana

Wellbeing is a crucial policy outcome within sustainable development, yet it can be measured and conceptualised in various ways. Methodological decisions, such as how different components are weighted, can influence wellbeing classification. Many studies utilise equal weighting, assuming each component is equally important; however, does this reflect communities' lived experiences? This study outlines a multidimensional basic needs deprivation measure constructed from the Deltas, Vulnerability and Climate Change: Migration and Adaptation (DECCMA) survey dataset in Volta Delta, Ghana. Participatory focus groups, interviews and weighting exercises with communities and District Planning Officers (DPOs) explore different subgroups' wellbeing priorities. Comparative analysis examines the weights provided across genders, decision-making levels and livelihoods; including farming, fishing and peri-urban groups. Objective survey data is also combined with various subjective weights to explore the sensitivity of the overall deprivation rate and its spatial distribution. Significant weight differences are found between livelihoods, with farming and fishing communities weighting "employment", "bank access", and "cooperative membership" higher, whereas peri-urban communities apply a greater weight to "healthcare access". Differences between decision-making levels are also noted. Community members weight "employment" higher, while DPOs assign a larger score to "cooperative membership". In contrast, consistent weights emerge across genders. Furthermore, applying community livelihood weights produces lower deprivation rates across most communities compared to DPO or equal nested weights. Overall, significant differences between subgroups' weights and the sensitivity of wellbeing measurement to weighting selection illustrate the importance of not only collecting local weights, but also where and whom you collect weightings from matters.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11205-025-03524-x.

Mixed vulnerabilities: the biological risk of high parity is aggravated by emergency referral in Benin, Malawi, Tanzania and Uganda

Identification of interacting vulnerabilities is essential to reduce maternal and perinatal mortality in sub-Saharan Africa (SSA). High parity (≥ 5 previous births) is an underemphasized biological vulnerability linked to poverty and affecting a sizeable proportion of SSA births. Despite increased risk, high parity women rarely use hospitals for childbirth. We assessed whether emergency referral during childbirth was associated with adverse events in high parity women in hospitals in Benin, Malawi, Tanzania and Uganda. We used e-registry data collected in 16 hospitals included in the Action Leveraging Evidence to Reduce perinatal morbidity and morTality (ALERT) trial. Main outcomes were severe maternal outcomes and in-facility peripartum death (fresh stillbirth or very early neonatal death). Main exposure was parity; emergency (in-labour) referral was included as effect modifier with potential confounders. We used multivariable logistic regression including parity/referral interaction and post-regression margins analysis. Among 80,663 births, 4,742 (5.9%) were to high parity women. One third reached hospital following emergency referral. Severe maternal outcomes and peripartum mortality were over 2.5-fold higher in high parity women with emergency referral compared to the lowest risk group. To avert these adverse events, emergency referral must be avoided by ensuring high parity women give birth in hospitals. Trial registration Pan African Clinical Trial Registry ( www.pactr.org ): PACTR202006793783148. Registered on 17th June 2020.

A time-stratified, case-crossover study of heat exposure and perinatal mortality from 16 hospitals in sub-Saharan Africa

Growing evidence suggests that extreme heat events affect both pregnant women and their infants, but few studies are available from sub-Saharan Africa. Using data from 138,015 singleton births in 16 hospitals in Benin, Malawi, Tanzania and Uganda, we investigated the association between extreme heat and early perinatal deaths, including antepartum and intrapartum stillbirths, and deaths within 24 h after birth using a time-stratified case-crossover design. We observed an association between an increase from the 75th to the 99th percentile in mean temperature 1 week (lag 0-6 d) before childbirth and perinatal mortality (odds ratio (OR) = 1.34 (95% confidence interval (CI) 1.01-1.78)). The estimates for stillbirths were similarly positive, but CIs included unity: OR = 1.29 (95% CI 0.95-1.77) for all stillbirths, OR = 1.18 (95% CI 0.71-1.95) for antepartum stillbirths and OR = 1.64 (95% CI 0.74-3.63) for intrapartum stillbirths. The cumulative exposure-response curve suggested that the steepest slopes for heat for intrapartum stillbirths and associations were stronger during the hottest seasons. We conclude that short-term heat exposure may increase mortality risks, particularly for intrapartum stillbirths, raising the importance of improved intrapartum care.

Bridging Data Gaps: Predicting Sub-national Maternal Mortality Rates in Kenya Using Machine Learning Models

Introduction Maternal mortality remains a critical global health issue, with ongoing efforts to reduce its incidence as part of international health priorities. Kenya, a sub-Saharan country that has a disproportionate number of maternal mortality is likely to miss this target unless evidence-based interventions are deployed. The paucity of reliable maternal health data calls for the development of alternative predictive models to complement the impaired civil registration system and the aperiodic national surveys. Methods We utilized DHS surveys from several Sub-Saharan African countries to estimate parameters for predicting Kenya's maternal mortality rate (MMR) in the absence of recent Kenya Demographic and Health Survey (KDHS) data. We developed a multiple linear regression model using supervised machine learning using the R-programming suite. Our model leverages machine learning techniques to analyze regional trends and predict sub-national MMR variations. We then applied the model to predict MMR for Kenyan counties using the data for the KDHS 2022 survey.  Results Using Pearson's correlation, we observed a significant positive correlation between MMR and total fertility (r = 0.32, p = 0.025) and a significant negative correlation between MMR and maternal age at first birth (r = -0.40, p = 0.005). Additionally, a significant correlation was observed with the cumulative percentage of mothers attending post-natal clinics, the prevalence of thinness (r = 0.77, p < 0.001), HIV infection in women (r = 0.20, p = 0.164), and physical violence during pregnancy. The model estimate of national MMR in 2022 was 367 deaths per 100,000 live births, ranging from 49 deaths per 100,000 live births in Kisii County to 1794 deaths per 100,000 live births in Turkana County. Conclusion Although MMR in Kenya displayed a general downward trend, our model's estimates for DHS 2022 indicate an increase compared to the 2019 National Census and Housing Survey estimate of 355 deaths per 100,000 live births. This rise may be attributed to COVID-19-related maternal deaths during the same period. The integration of predictive models to inform interventions and resource allocation could play a crucial role in enhancing maternal healthcare outcomes in Kenya.

Structural barriers to maternity care in Cameroon: a qualitative study

BACKGROUND

The maternal mortality and perinatal mortality rate in Cameroon are among the highest worldwide. To improve these outcomes, we conducted a formative qualitative assessment to inform the adaptation of a mobile provider-to-provider intervention in Cameroon. We explored the complex interplay of structural barriers on maternity care in this low-resourced nation. The study aimed to identify structural barriers to maternal care during the early adaptation of the mobile Medical Information Service via Telephone (mMIST) program in Cameroon.

METHODS

We conducted in-depth interviews and focus groups with 56 key stakeholders including previously and currently pregnant women, primary healthcare providers, administrators, and representatives of the Ministry of Health, recruited by purposive sampling. Thematic coding and analysis via modified grounded theory approach were conducted using NVivo12 software.

RESULTS

Three main structural barriers emerged: (1) civil unrest (conflict between Ambazonian militant groups and the Cameroonian government in the Northwest), (2) limitations of the healthcare system, (3) inadequate physical infrastructure. Civil unrest impacted personal security, transportation safety, and disrupted medical transport system. Limitations of healthcare system involved critical shortages of skilled personnel and medical equipment, low commitment to evidence-based care, poor reputation, ineffective health system communication, incentives affecting care, and inadequate data collection. Inadequate physical infrastructure included frequent power outages and geographic distribution of healthcare facilities leading to logistical challenges.

CONCLUSION

Dynamic inter-relations among structural level factors create barriers to maternity care in Cameroon. Implementation of policies and intervention programs addressing structural barriers are necessary to facilitate timely access and utilization of high-quality maternity care.

Exploring women's experiences of care during hospital childbirth in rural Tanzania: a qualitative study

BACKGROUND

Women's childbirth experiences provide a unique understanding of care received in health facilities from their voices as they describe their needs, what they consider good and what should be changed. Quality Improvement interventions in healthcare are often designed without inputs from women as end-users, leading to a lack of consideration for their needs and expectations. Recently, quality improvement interventions that incorporate women's childbirth experiences are thought to result in healthcare services that are more responsive and grounded in the end-user's needs.

AIM

This study aimed to explore women's childbirth experiences to inform a co-designed quality improvement intervention in Southern Tanzania.

METHODS

This exploratory qualitative study used semi-structured interviews with women after childbirth (n = 25) in two hospitals in Southern Tanzania. Reflexive thematic analysis was applied using the World Health Organization's Quality of Care framework on experiences of care domains.

RESULTS

Three themes emerged from the data: (1) Women's experiences of communication with providers varied (2) Respect and dignity during intrapartum care is not guaranteed; (3) Women had varying experience of support during labour. Verbal mistreatment and threatening language for adverse birthing outcomes were common. Women appreciated physical or emotional support through human interaction. Some women would have wished for more support, but most accepted the current practices as they were.

CONCLUSION

The experiences of care described by women during childbirth varied from one woman to the other. Expectations towards empathic care seemed low, and the little interaction women had during labour and birth was therefore often appreciated and mistreatment normalized. Potential co-designed interventions should include strategies to (i) empower women to voice their needs during childbirth and (ii) support healthcare providers to have competencies to be more responsive to women's needs.

Association of maternal, obstetric, fetal, and neonatal mortality outcomes with Lady Health Worker coverage from a cross-sectional survey of >10,000 households in Gilgit-Baltistan, Pakistan

Pakistan has among the highest rates of maternal, perinatal, and neonatal mortality globally. Many of these deaths are potentially preventable with low-cost, scalable interventions delivered through community-based health worker programs to the most remote communities. We conducted a cross-sectional survey of 10,264 households during the baseline phase of a cluster randomized controlled trial (cRCT) in Gilgit-Baltistan, Pakistan from June-August 2021. The survey was conducted through a stratified, two-stage sampling design with the objective of estimating the neonatal mortality rate (NMR) within the study catchment area, and informing implementation of the cRCT. Study outcomes were self-reported and included neonatal death, stillbirth, health facility delivery, maternal death, postpartum hemorrhage (PPH), and Lady Health Worker (LHW) coverage. Summary statistics (proportions and rates) were weighted according to the sampling design, and mixed-effects Poisson regression was conducted to explore the relationship between LHW coverage and maternal/newborn outcomes. We identified 7,600 women who gave birth in the past five years, among whom 13% reported experiencing PPH. The maternal mortality ratio was 225 maternal deaths per 100,000 live births (95% confidence interval [CI] 137-369). Among 12,376 total births, the stillbirth rate was 41.4 per 1,000 births (95% CI 36.8-46.7) and the perinatal mortality rate was 53.0 per 1,000 births (95% CI 47.6-59.0). Among 11,863 live births, NMR was 16.2 per 1,000 live births (95% CI 13.6-19.3) and 65% were delivered at a health facility. LHW home visits were associated with declines in PPH (risk ratio [RR] 0.89 per each additional visit, 95% CI 0.83-0.96) and late neonatal mortality (RR 0.80, 95% CI 0.67-0.97). Intracluster correlation coefficients were also estimated to inform the planning of future trials. The high rates of maternal, perinatal, and neonatal death in Gilgit-Baltistan continue to fall behind targets of the 2030 Sustainable Development Goals.

Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data

INTRODUCTION

Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity.

METHODS

Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators.

RESULTS

This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda.

DISCUSSION

Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.

Using national census data to facilitate healthcare research

National censuses are conducted at varying intervals across both the developed and developing world and collect detailed data on a wide range of societal, economic and health questions. This immense volume of data has many potential uses in the field of healthcare research and can be utilised either in isolation or in conjunction with other information sources such as hospital records. At a governmental level census data can be used for healthcare service planning by providing accurate population density information but also, through the use of more detailed data collection, by helping to identify high-risk populations that may require increased resource allocation. It can also be a key tool in addressing and improving healthcare inequality and deprivation by both identifying those populations with poorer healthcare outcomes and through helping researchers to better understand the causes of this inequality. Similarly, it has utility when studying the complex causes of disease and assessing the success of strategies designed to tackle these aetiologies. However, the maximum benefit from these various uses can only be realised if the data collection and analysis processes utilised are robust and this requires that census bureaus regularly review and modify their methods in a transparent and thorough way.

Impacts of seasonal flooding on geographical access to maternal healthcare in the Barotse Floodplain, Zambia

BACKGROUND

Seasonal floods pose a commonly-recognised barrier to women's access to maternal services, resulting in increased morbidity and mortality. Despite their importance, previous GIS models of healthcare access have not adequately accounted for floods. This study developed new methodologies for incorporating flood depths, velocities, and extents produced with a flood model into network- and raster-based health access models. The methodologies were applied to the Barotse Floodplain to assess flood impact on women's walking access to maternal services and vehicular emergency referrals for a monthly basis between October 2017 and October 2018.

METHODS

Information on health facilities were acquired from the Ministry of Health. Population density data on women of reproductive age were obtained from the High Resolution Settlement Layer. Roads were a fusion of OpenStreetMap and data manually delineated from satellite imagery. Monthly information on floodwater depth and velocity were obtained from a flood model for 13-months. Referral driving times between delivery sites and EmOC were calculated with network analysis. Walking times to the nearest maternal services were calculated using a cost-distance algorithm.

RESULTS

The changing distribution of floodwaters impacted the ability of women to reach maternal services. At the peak of the dry season (October 2017), 55%, 19%, and 24% of women had walking access within 2-hrs to their nearest delivery site, EmOC location, and maternity waiting shelter (MWS) respectively. By the flood peak, this dropped to 29%, 14%, and 16%. Complete inaccessibility became stark with 65%, 76%, and 74% unable to access any delivery site, EmOC, and MWS respectively. The percentage of women that could be referred by vehicle to EmOC from a delivery site within an hour also declined from 65% in October 2017 to 23% in March 2018.

CONCLUSIONS

Flooding greatly impacted health access, with impacts varying monthly as the floodwave progressed. Additional validation and application to other regions is still needed, however our first results suggest the use of a hydrodynamic model permits a more detailed representation of floodwater impact and there is great potential for generating predictive models which will be necessary to consider climate change impacts on future health access.

Place of death and associated factors among reviewed maternal deaths in Ethiopia: a generalised structural equation modelling

OBJECTIVE

The study aims to determine the magnitude and factors that affect maternal death in different settings.

DESIGN, SETTING AND ANALYSIS

A review of national maternal death surveillance data was conducted. The data were obtained through medical record review and verbal autopsies of each death. Generalised structural equation modelling was employed to simultaneously examine the relationships among exogenous, mediating (urban/rural residence) and endogenous variables.

OUTCOME

Magnitude and factors related to the location of maternal death.

PARTICIPANTS

A total of 4316 maternal deaths were reviewed from 2013 to 2020.

RESULTS

Facility death constitutes 69.0% of maternal deaths in the reporting period followed by home death and death while in transit, each contributing to 17.0% and 13.6% of maternal deaths, respectively. Educational status has a positive direct effect on death occurring at home (β=0.42, 95% CI 0.22 to 0.66), obstetric haemorrhage has a direct positive effect on deaths occurring at home (β=0.41, 95% CI 0.04 to 0.80) and death in transit (β=0.68, 95% CI 0.48 to 0.87), while it has a direct negative effect on death occurring at a health facility (β=-0.60, 95% CI -0.77 to -0.44). Moreover, unanticipated management of complication has a positive direct (β=0.99, 95% CI 0.34 to 1.63), indirect (β=0.05, 95% CI 0.04 to 0.07) and total (β=1.04, 95% CI 0.38 to 1.70) effect on facility death. Residence is a mediator variable and is associated with all places of death. It has a connection with facility death (β=-0.70, 95% CI -0.95 to -0.46), death during transit (β=0.51, 95% CI 0.20 to 0.83) and death at home (β=0.85, 95% CI 0.54 to 1.17).

CONCLUSION

Almost 7 in 10 maternal deaths occurred at the health facility. Sociodemographic factors, medical causes of death and non-medical causes of death mediated by residence were factors associated with the place of death. Thus, factors related to the place of death should be considered as an area of intervention to mitigate preventable maternal death that occurred in different settings.

Quality of maternal healthcare and travel time influence birthing service utilisation in Ghanaian health facilities: a geographical analysis of routine health data

OBJECTIVES

To investigate how the quality of maternal health services and travel times to health facilities affect birthing service utilisation in Eastern Region, Ghana.

DESIGN

The study is a cross-sectional spatial interaction analysis of birth service utilisation patterns. Routine birth data were spatially linked to quality care, service demand and travel time data.

SETTING

131 Health facilities (public, private and faith-based) in 33 districts in Eastern Region, Ghana.

PARTICIPANTS

Women who gave birth in health facilities in the Eastern Region, Ghana in 2017.

OUTCOME MEASURES

The count of women giving birth, the quality of birthing care services and the geographic coverage of birthing care services.

RESULTS

As travel time from women's place of residence to the health facility increased up to two2 hours, the utilisation rate markedly decreased. Higher quality of maternal health services haves a larger, positive effect on utilisation rates than service proximity. The quality of maternal health services was higher in hospitals than in primary care facilities. Most women (88.6%) travelling via mechanised transport were within two2 hours of any birthing service. The majority (56.2%) of women were beyond the two2 -hour threshold of critical comprehensive emergency obstetric and newborn care (CEmONC) services. Few CEmONC services were in urban centres, disadvantaging rural populations.

CONCLUSIONS

To increase birthing service utilisation in Ghana, higher quality health facilities should be located closer to women, particularly in rural areas. Beyond Ghana, routinely collected birth records could be used to understand the interaction of service proximity and quality.

Mortality Rate and Predictors Among Women With Obstructed Labor in a Tertiary Academic Medical Center of Ethiopia: A Retrospective Cohort Study

Introduction

Obstructed labor is one of the most common preventable causes of maternal morbidity and mortality. In Ethiopia, 36% of maternal mortality was due to obstructed labor with uterine rupture. Thus, this study proposed to measure predictors of maternal mortality among women with obstructed labor in a tertiary academic medical center in Southern Ethiopia.

Methods

An institution-based retrospective cohort study was conducted at Hawassa University Specialized Hospital from July 25 to September 30, 2018. Women who had obstructed labor from 2015 to 2017 were recruited. A pretested checklist was used to retrieve data from the woman's chart. A multivariable logistic regression model was employed to identify variables associated with maternal mortality, and variables with a p-value <.05 were considered significant at 95% CI.

Results

With a response rate of 96.3%, 156 moms who experienced labor obstruction were included in the study. Obstructed labor caused the deaths of 14 women, resulting in a maternal mortality rate of 8.9% (95% CI: 7.15, 16.4). Maternal mortality from obstructed labor was reduced in women who received antenatal care visits (AOR = 0.25, 95% CI: 0.13, 0.76) and blood transfusions (AOR =  0.49, 95% CI: 0.03, 0.89). Women who experienced uterine rupture (AOR =  6.25, 95% CI: 5.3, 15.6) and antepartum hemorrhage (AOR = 14, 95% CI: 2.45, 70.5) had a greater risk of maternal mortality than women who did not have the corresponding morbidity.

Conclusions

The center had a higher rate of maternal mortality due to obstructed labor. Early screening and improving the care for women at greatest risk of antenatal and postnatal co-morbidities like uterine rupture and shock were the major priorities and fundamental strategies to decreasing maternal mortality. It also showed that antenatal care visits, early referral, and blood transfusion for women with obstructed labor should be amended in order to lower maternal mortality.

Evaluation of a comprehensive maternal newborn health intervention in rural Tanzania: single-arm pre-post coverage survey results

Background

In Tanzania, maternal and newborn deaths can be prevented via quality facility-based antenatal care (ANC), delivery, and postnatal care (PNC). Scalable, integrated, and comprehensive interventions addressing demand and service-side care-seeking barriers are needed.

Objective

Assess coverage survey indicators before and after a comprehensive maternal newborn health (MNH) intervention in Misungwi District, Tanzania.

Methods

A prospective, single-arm, pre- (2016) and post-(2019) coverage survey (ClinicalTrials.gov #NCT02506413) was used to assess key maternal and newborn health (MNH) outcomes. The Mama na Mtoto intervention included district activities (planning, leadership training, supportive supervision), health facility activities (training, equipment, infrastructure upgrades), and plus community health worker mobilization. Implementation change strategies, a process model, and a motivational framework incorporated best practices from a similar Ugandan intervention. Cluster sampling randomized hamlets then used ‘wedge sampling’ protocol as an alternative to full household enumeration. Key outcomes included: four or more ANC visits (ANC4+); skilled birth attendant (SBA); PNC for mother within 48 hours (PNC-woman); health facility delivery (HFD); and PNC for newborn within 48 hours (PNC-baby). Trained interviewers administered the ‘Real Accountability: Data Analysis for Results Coverage Survey to women 15–49 years old. Descriptive statistics incorporated design effect; the Lives Saved Tool estimated deaths averted based on ANC4+/HFD.

Results

Between baseline (n = 2,431) and endline (n = 2,070), surveys revealed significant absolute percentage increases for ANC4+ (+11.6, 95% CI [5.4, 17.7], p < 0.001), SBA (+16.6, 95% CI [11.1, 22.0], p < 0.001), PNC-woman (+9.2, 95% CI [3.2, 15.2], p = 0.002), and HFD (+17.2%, 95% CI [11.3, 23.1], p < 0.001). A PNC-baby increase (+6.1%, 95% CI [−0.5, 12.8], p = 0.07) was not statistically significant. An estimated 121 neonatal and 20 maternal lives were saved between 2016 and 2019.

Conclusions

Full-district scale-up of a comprehensive MNH package embedded government health system was successfully implemented over a short time and associated with significant maternal care-seeking improvements and potential for lives saved.

Readiness of health facilities to provide safe childbirth in Liberia: a cross-sectional analysis of population surveys, facility censuses and facility birth records

BACKGROUND

The provision of quality obstetric care in health facilities is central to reducing maternal mortality, but simply increasing childbirth in facilities not enough, with evidence that many facilities in sub-Saharan Africa do not fulfil even basic requirements for safe childbirth care. There is ongoing debate on whether to recommend a policy of birth in hospitals, where staffing and capacity may be better, over lower level facilities, which are closer to women's homes and more accessible. Little is known about the quality of childbirth care in Liberia, where facility births have increased in recent decades, but maternal mortality remains among the highest in the world. We will analyse quality in terms of readiness for emergency care and referral, staffing, and volume of births.

METHODS

We assessed the readiness of the Liberian health system to provide safe care during childbirth use using three data sources: Demographic and Health Surveys (DHS), Service Availability and Readiness Assessments (SARA), and the Health Management Information System (HMIS). We estimated trends in the percentage of births by location and population caesarean-section coverage from 3 DHS surveys (2007, 2013 and 2019-20). We examined readiness for safe childbirth care among all Liberian health facilities by analysing reported emergency obstetric and neonatal care signal functions (EmONC) and staffing from SARA 2018, and linking with volume of births reported in HMIS 2019.

RESULTS

The percentage of births in facilities increased from 37 to 80% between 2004 and 2017, while the caesarean section rate increased from 3.3 to 5.0%. 18% of facilities could carry out basic EmONC signal functions, and 8% could provide blood transfusion and caesarean section. Overall, 63% of facility births were in places without full basic emergency readiness. 60% of facilities could not make emergency referrals, and 54% had fewer than one birth every two days.

CONCLUSIONS

The increase in proportions of facility births over time occurred because women gave birth in lower-level facilities. However, most facilities are very low volume, and cannot provide safe EmONC, even at the basic level. This presents the health system with a serious challenge for assuring safe, good-quality childbirth services.

Self-referrals and associated factors among laboring mothers at Dilla University Referral Hospital, Dilla, Gedeo Zone, Ethiopia: a cross-sectional study

BACKGROUND

When medical cases are difficult to manage at the level of primary health care units (PHCU), formal referral assists patients transferring to a higher level of care. In contrast, self-referral and bypassing are synonymously used in literature to describe the phenomenon of patients skipping their units to get basic medical services, even though they are close to their residence. Though proper and timely referral prevents the majority of deaths from obstetric complications in developing countries, more than 50% of referrals are self-referral trends. Such patient practice is increasingly becoming a concern for many health-care systems.

OBJECTIVE

To assess the magnitude of self-referrals and associated factors among laboring mothers at Gedeo Zone, Ethiopia.

METHODS

Facility-based cross-sectional study was conducted from August 1-September 30/2021 among laboring mothers at Dilla University Referral Hospital. A systematic random sampling technique was used to select 375 laboring mothers. Data were collected using a face-to-face interview with a structured questionnaire. Data were entered into a computer using Epi-Data 4.6 statistical program and then exported to STATA version 16 for analysis. In bivariate analysis variables with a p-value ≤ 0.25 were selected as a candidate variable for the multivariable analysis. P-value < 0.05 at 95% confidence interval considered as a statistically significant associations in the multivariable analysis.

RESULT

375 eligible mothers participated in the study, with a response rate of 98.16%. The magnitude of self-referrals among laboring mothers was 246 (65.6%) with 95% CI (0.60-0.70). Time ≥ 30 min to reach nearby facilities (AOR = 1.74, 95% CI, 1.08, 2.81), having no medicine supplies at nearby facilities (AOR = 1.75, 95% CI, 1.08, 2.82), having no equipment and supplies at nearby facilities (AOR = 1.70, 95% CI, 1.03, 2.78), having ANC visits ˃ 3 times (AOR = 0.29, 95% CI, 0.15, 0.55) and having poor perception of health provider technical competence at nearby facilities (AOR = 2.97, 95% CI, 1.83, 4.79) were found as significant factors for self-referral.

CONCLUSION

The magnitude of self-referral was high. Frequent Antenatal visits were protective, however time to reach the nearest facilities, perception towards health care providers, medicine, equipment and supplies at the nearest facilities were positive influencing factors. Government stakeholders should keep working on improving the quality of health service, especially at primary health care units(PHCU).

Distance is “a big problem”: a geographic analysis of reported and modelled proximity to maternal health services in Ghana

Background

Geographic barriers to healthcare are associated with adverse maternal health outcomes. Modelling travel times using georeferenced data is becoming common in quantifying physical access. Multiple Demographic and Health Surveys ask women about distance-related problems accessing healthcare, but responses have not been evaluated against modelled travel times. This cross-sectional study aims to compare reported and modelled distance by socio-demographic characteristics and evaluate their relationship with skilled birth attendance. Also, we assess the socio-demographic factors associated with self-reported distance problems in accessing healthcare.

Methods

Distance problems and socio-demographic characteristics reported by 2210 women via the 2017 Ghana Maternal Health Survey were included in analysis. Geospatial methods were used to model travel time to the nearest health facility using roads, rivers, land cover, travel speeds, cluster locations and health facility locations. Logistic regressions were used to predict skilled birth attendance and self-reported distance problems.

Results

Women reporting distance challenges accessing healthcare had significantly longer travel times to the nearest health facility. Poverty significantly increased the odds of reporting challenges with distance. In contrast, living in urban areas and being registered with health insurance reduced the odds of reporting distance challenges. Women with a skilled attendant at birth, four or more skilled antenatal appointments and timely skilled postnatal care had shorter travel times to the nearest health facility. Generally, less educated, poor, rural women registered with health insurance had longer travel times to their nearest health facility. After adjusting for socio-demographic characteristics, the following factors increased the odds of skilled birth attendance: wealth, health insurance, higher education, living in urban areas, and completing four or more antenatal care appointments.

Conclusion

Studies relying on modelled travel times to nearest facility should recognise the differential impact of geographic access to healthcare on poor rural women. Physical access to maternal health care should be scaled up in rural areas and utilisation increased by improving livelihoods.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04998-0.

Improving access to emergency obstetric care in underserved rural Tanzania: a prospective cohort study

Background

One of the key strategies to reducing maternal mortality is provision of emergency obstetric care services. This paper describes the results of improving availability of, and access to emergency obstetric care services in underserved rural Tanzania using associate clinicians.

Methods

A prospective cohort study of emergency obstetric care was implemented in seven health centres in Morogoro region, Tanzania from July 2016 to June 2019. In early 2016, forty-two associate clinicians from five health centres were trained in teams for three months in emergency obstetric care, newborn care and anaesthesia. Two health centres were unexposed to the intervention and served as controls. Following training, virtual teleconsultation, quarterly on-site supportive supervision and continuous mentorship were implemented to reinforce skills and knowledge.

Results

The met need for emergency obstetric care increased significantly from 45% (459/1025) at baseline (July 2014 – June 2016) to 119% (2010/1691) during the intervention period (Jul 2016 – June 2019). The met need for emergency obstetric care in the control group also increased from 53% (95% CI 49–58%) to 77% (95% CI 74–80%). Forty maternal deaths occurred during the baseline and intervention periods in the control and intervention health centres. The direct obstetric case fatality rate decreased slightly from 1.5% (95% CI 0.6–3.1%) to 1.1% (95% CI 0.7–1.6%) in the intervention group and from 3.3% (95% CI 1.2–7.0%) to 0.8% (95% CI 0.2–1.7%) in the control group.

Conclusions

When emergency obstetric care services are made available the proportion of obstetric complications treated in the facilities increases. However, the effort to scale up emergency obstetric care services in underserved rural areas should be accompanied by strategies to reinforce skills and the referral system.

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

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

Factors Associated with Underutilization of Maternity Health Care Cascade in Mozambique: Analysis of the 2015 National Health Survey

Maternity health care services utilization determines maternal and neonate outcomes. Evidence about factors associated with composite non-utilization of four or more antenatal consultations and intrapartum health care services is needed in Mozambique. This study uses data from the 2015 nationwide Mozambique’s Malaria, Immunization and HIV Indicators Survey. At selected representative households, women (n = 2629) with child aged up to 3 years answered a standardized structured questionnaire. Adjusted binary logistic regression assessed associations between women-child pairs characteristics and non-utilization of maternity health care. Seventy five percent (95% confidence interval (CI) = 71.8–77.7%) of women missed a health care cascade step during their last pregnancy. Higher education (adjusted odds ratio (AOR) = 0.65; 95% CI = 0.46–0.91), lowest wealth (AOR = 2.1; 95% CI = 1.2–3.7), rural residency (AOR = 1.5; 95% CI = 1.1–2.2), living distant from health facility (AOR = 1.5; 95% CI = 1.1–1.9) and unknown HIV status (AOR = 1.9; 95% CI = 1.4–2.7) were factors associated with non-utilization of the maternity health care cascade. The study highlights that, by 2015, recommended maternity health care cascade utilization did not cover 7 out of 10 pregnant women in Mozambique. Unfavorable sociodemographic and economic factors increase the relative odds for women not being covered by the maternity health care cascade.

Determinants of obstructed labour and its adverse outcomes among women who gave birth in Hawassa University referral Hospital: A case-control study

Background

Globally, obstructed labour accounted for 22% of maternal morbidities and up to 70% of perinatal deaths. It is one of the most common preventable causes of maternal and perinatal mortality in low-income countries. However, there are limited studies on the determinants of obstructed labor in Ethiopia. Therefore, this study was conducted to assess determinants and outcomes of obstructed labor among women who gave birth in Hawassa University Hospital, Ethiopia.

Methods

A hospital-based case-control study design was conducted in Hawassa University Hospital among 468 women. All women who were diagnosed with obstructed labour and two consecutive controls giving birth on the same day were enrolled in this study. A pretested data extraction tool was used for data collection from the patient charts. Multivariable logistic regression was employed to identify determinants of obstructed labor.

Results

A total of 156 cases and 312 controls were included with an overall response rate of 96.3%. Women who were primipara [AOR 0.19; 95% CI 0.07, 0.52] and multigravida [AOR 0.17; 95% CI 0.07, 0.41] had lower odds of obstructed labour. While contracted pelvis [AOR 3.98; 95% CI 1.68, 9.42], no partograph utilization [AOR 5.19; 95% CI 1.98, 13.6], duration of labour above 24 hours [AOR 7.61; 95% CI 2.98, 19.8] and estimated distance of 10 to 50 kilometers from the hospital [AOR 3.89; 95% CI 1.14, 13.3] had higher odds. Higher percentage of maternal (65.2%) and perinatal (60%) complications occurred among cases (p-value < 0.05). Obstructed labour accounted for 8.3% of maternal deaths and 39.7% of stillbirth. Uterine rupture, post-partum haemorrhage and sepsis were the common adverse outcomes among cases.

Conclusion

Parity, contracted pelvis, non-partograph utilization, longer duration of labour and longer distance from health facilities were determinants of obstructed labour. Maternal and perinatal morbidity and mortality due to obstructed labour are higher. Therefore, improvement of partograph utilization to identify complications early, birth preparedness, complication readiness and provision of timely interventions are recommended to prevent such complications.

The utilization of maternal health services at primary healthcare setting in Southeast Asian Countries: A systematic review of the literature

The reduction of Maternal Mortality Ratio (MMR) remains a global health issue. Although major progress has been achieved in the past 15 years, the ratio is still high, especially in Low Middle-Income Countries. In the Southeast Asian region, most of the countries have not reached the Sustainable Development Goals target yet. Although the countries have several similarities in many aspects, such as community characteristics, cultural context, health systems, and geographical proximity, the MMR in the region presents interesting variations. The scope of this systematic review is to explore published literature on the utilization of maternal health services at the community healthcare centre setting in Southeast Asian countries. The databases PubMed, Web of Science, and Google Scholar were searched systematically to identify quantitative, qualitative and mixed methods studies published in 2000-2020. A total of 1876 records were found, out of which 353 full text were screened. Finally, 27 studies on utilization of maternal health services met the inclusion criteria and were selected for analysis from seven Southeast Asian countries: Cambodia, Indonesia, Lao PDR, Myanmar, The Philippines, Timor Leste and Vietnam. Most of the articles focused on the utilization of maternal health services at primary health care setting. Several themes on maternal health services utilization in the countries emerged, including cultural and socioeconomic factors contributed to the utilization of maternal health services, factors associated with the low utilization of ANC, determinants affected place of delivery and delivery assistance choice. The utilization of maternal health services at primary healthcare setting in seven Southeast Asian countries was identified in a small number of studies. Sociocultural barriers and disparities of health services provision are the major factors associated with low utilization of the services. Further research on strengthening the role of primary healthcare in maternal health services provision is required.

Comparing absolute and relative distance and time travel measures of geographic access to healthcare facilities in rural Haiti

INTRODUCTION

While travel distance and time are important proxies of physical access to health facilities, obtaining valid measures with an appropriate modelling method remains challenging in many settings. We compared five measures of geographic accessibility in Haiti, producing recommendations that consider available analytic resources and geospatial goals.

METHODS

Eight public hospitals within the ministry of public health and population were included. We estimated distance and time between hospitals and geographic centroids of Haiti's section communes and population-level accessibility. Geographic feature data were obtained from public administrative databases, academic research databases and government satellites. We used validated geographic information system methods to produce five geographic access measures: (1) Euclidean distance (ED), (2) network distance (ND), (3) network travel time (NTT), (4) AccessMod 5 (AM5) distance (AM5D) and (5) AM5 travel time (AM5TT). Relative ranking of section communes across the measures was assessed using Pearson correlation coefficients, while mean differences were assessed using analysis of variance (ANOVA) and pairwise t-tests.

RESULTS

All five geographic access measures were highly correlated (range: 0.78-0.99). Of the distance measures, ED values were consistently the shortest, followed by AM5D values, while ND values were the longest. ND values were as high as 2.3 times ED values. NTT models generally produced longer travel time estimates compared with AM5TT models. ED consistently overestimated population coverage within a given threshold compared with ND and AM5D. For example, population-level accessibility within 15 km of the nearest studied hospital in the Center department was estimated at 68% for ED, 50% for AM5D and 34% for ND.

CONCLUSION

While the access measures were highly correlated, there were significant differences in the absolute measures. Consideration of the benefits and limitations of each geospatial measure together with the intended purpose of the estimates, such as relative proximity of patients or service coverage, are key to guiding appropriate use.

Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study

Introduction

Prompt access to emergency obstetrical care (EmOC) reduces the risk of maternal mortality. We assessed institutional maternal mortality by distance and travel time for pregnant women with obstetrical emergencies in Lagos State, Nigeria.

Methods

We conducted a facility-based retrospective cohort study across 24 public hospitals in Lagos. Reviewing case notes of the pregnant women presenting between 1 November 2018 and 30 October 2019, we extracted socio-demographic, travel and obstetrical data. The extracted travel data were exported to Google Maps, where driving distance and travel time data were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on maternal death.

Findings

Of 4181 pregnant women with obstetrical emergencies, 182 (4.4%) resulted in maternal deaths. Among those who died, 60.3% travelled ≤10 km directly from home, and 61.9% arrived at the hospital ≤30 mins. The median distance and travel time to EmOC was 7.6 km (IQR 3.4–18.0) and 26 mins (IQR 12–50). For all women, travelling 10–15 km (2.53, 95% CI 1.27 to 5.03) was significantly associated with maternal death. Stratified by referral, odds remained statistically significant for those travelling 10–15 km in the non-referred group (2.48, 95% CI 1.18 to 5.23) and for travel ≥120 min (7.05, 95% CI 1.10 to 45.32). For those referred, odds became statistically significant at 25–35 km (21.40, 95% CI 1.24 to 36.72) and for journeys requiring travel time from as little as 10–29 min (184.23, 95% CI 5.14 to 608.51). Odds were also significantly higher for women travelling to hospitals in suburban (3.60, 95% CI 1.59 to 8.18) or rural (2.51, 95% CI 1.01 to 6.29) areas.

Conclusion

Our evidence shows that distance and travel time influence maternal mortality differently for referred women and those who are not. Larger scale research that uses closer-to-reality travel time and distance estimates as we have done, rethinking of global guidelines, and bold actions addressing access gaps, including within the suburbs, will be critical in reducing maternal mortality by 2030.

Challenges and Suggestions to Promote Maternal Service Provision and Utilization Under the Free Maternal Health Policy in Ghana: Perspectives of Health Directors and Facility Managers

INTRODUCTION

To promote service uptake and reduce maternal deaths, a policy was implemented under Ghana’s National Health Insurance Scheme in 2008. This study explored the benefits and limitations of the policy, health system challenges, and community-level challenges resulting in suggestions to mitigate the challenges.

METHODS

The study design was cross-sectional, utilizing qualitative data collection. It was carried out in the Kassena-Nankana East Municipality, Ghana, involving in-depth interviews (IDIs) with directors of Ghana Health Service and facility managers. A total of eight IDIs were conducted. Data were transcribed, read, and analyzed based on themes which were presented using key quotes.

RESULTS

The policy promoted the use of services. Nonetheless, challenges existed as a result of limited service coverage, inadequate human resources and infrastructure, lack of medications and equipment, lack of transport, and the influence of religion, culture, and family members. There was a need to strategize so that women with a low socioeconomic status would receive service over those of a high socioeconomic status. Other suggestions included the inclusion of family planning services, accreditation of private facilities, provision of a shift system for specialists to move to rural areas, and provision of incentives for health personnel in rural areas. It was also suggested that health personnel make known their challenges as well as to provide education on women’s rights and service expectations. The provision of transport vouchers to women as well as alternative arrangements to be made with private transport owners were also suggested.

CONCLUSION

Implementing the suggestions may improve service provision and utilization leading to the reduction of maternal deaths and contributing towards achieving universal health coverage.

Geographic Access and Maternal Health Services Utilization in Sélingué Health District, Mali

Introduction

Maternal mortality is one of the main causes of death for women of childbearing age in Mali, and improving this outcome is slow, even in regions with relatively good geographic access to care. Disparities in maternal health services utilization can constitute a major obstacle in the reduction of maternal mortality in Mali and indicates a lack of equity in the Malian health system. Literature on maternal health inequity has explored structural and individual factors influencing outcomes but has not examined inequities in health facility distribution within districts with moderate geographic access. The purpose of this article is to examine disparities in education and geographic distance and how they affect utilization of maternal care within the Sélingué health district, a district with moderate geographic access to care, near Bamako, Mali.

Methods

We conducted a cross sectional survey with cluster sampling in the Sélingué health district. Maternal health services characteristics and indicators were described. Association between dependent and independent variables was verified using Kendall’s tau-b correlation, Chi square, logistic regression with odds ratio and 95% confidence interval. Gini index and concentration curve were used to measure inequity.

Results

Most respondents were 20 to 24 years old. Over 31% of our sample had some education, 65% completed at least four ANC visits, and 60.8% delivered at a health facility. Despite this evidence of healthcare access in Sélingué, disparities within the health district contribute to inadequate utilization among approximately 40% of the women in our sample. The concentration index demonstrated the impact of inequity in geographic access,

comparing women residing near and far from the referral care facility.

Conclusion

Maternal health services underutilization, within a district with moderate geographic access, indicates that deliberate attention should be paid to addressing geographic access even in such a district.

Inequity in uptake of hospital-based childbirth care in rural Tanzania: analysis of the 2015-16 Tanzania Demographic and Health Survey

Proportions of facility births are increasing throughout sub-Saharan Africa, but obstetric services vary within the health system. In Tanzania, advanced management of childbirth complications (comprehensive emergency obstetric care) is offered in hospitals, while in frontline, primary health care (PHC) facilities (health centres and dispensaries) mostly only routine childbirth care is available. With over half (54%) of rural births in facilities, we hypothesized the presence of socio-economic inequity in hospital-based childbirth uptake in rural Tanzania and explored whether this relationship was modified by parity. This inequity may compound the burden of greater mortality among the poorest women and their babies. Records for 4456 rural women from the 2015-16 Tanzania Demographic and Health Survey with a live birth in the preceding 5 years were examined. Proportions of births at each location (home/PHC/hospital) were calculated by demographic and obstetric characteristics. Multinomial logistic regression was used to obtain crude and adjusted odds ratios of home/PHC and hospital/PHC births based on household wealth, including interaction between wealth and parity. Post-estimation margins analysis was applied to estimate childbirth location by wealth and parity. Hospital-based childbirth uptake was inequitable. The gap between poorest and richest was less pronounced at first birth. Hospital-based care utilization was lowest (around 10%) among the poorest multiparous women, with no increase at high parity (≥5) despite higher risk. PHC-based childbirth care was used by a consistent proportion of women after the first birth (range 30-51%). The poorest women utilized it at intermediate parity, but at parity ≥5 mostly gave birth at home. In an effort to provide effective childbirth care to all women, context-specific strategies are required to improve hospital-based care use, and poor, rural, high parity women are a particularly vulnerable group that requires specific attention. Improving childbirth care in PHC and strengthening referral linkages would benefit a considerable proportion of women.

Mobility for maternal health among women in hard-to-reach fishing communities on Lake Victoria, Uganda; a community-based cross-sectional survey

BACKGROUND

Maternal mortality is still a challenge in Uganda, at 336 deaths per 100,000 live births, especially in rural hard to reach communities. Distance to a health facility influences maternal deaths. We explored women's mobility for maternal health, distances travelled for antenatal care (ANC) and childbirth among hard-to-reach Lake Victoria islands fishing communities (FCs) of Kalangala district, Uganda.

METHODS

A cross sectional survey among 450 consenting women aged 15-49 years, with a prior childbirth was conducted in 6 islands FCs, during January-May 2018. Data was collected on socio-demographics, ANC, birth attendance, and distances travelled from residence to ANC or childbirth during the most recent childbirth. Regression modeling was used to determine factors associated with over 5 km travel distance and mobility for childbirth.

RESULTS

The majority of women were residing in communities with a government (public) health facility [84.2 %, (379/450)]. Most ANC was at facilities within 5 km distance [72 %, (157/218)], while most women had travelled outside their communities for childbirth [58.9 %, (265/450)]. The longest distance travelled was 257.5 km for ANC and 426 km for childbirth attendance. Travel of over 5 km for childbirth was associated with adolescent girls and young women (AGYW) [AOR = 1.9, 95 % CI (1.1-3.6)], up to five years residency duration [AOR = 1.8, 95 % CI (1.0-3.3)], and absence of a public health facility in the community [AOR = 6.1, 95 % CI (1.4-27.1)]. Women who had stayed in the communities for up to 5 years [AOR = 3.0, 95 % CI (1.3-6.7)], those whose partners had completed at least eight years of formal education [AOR = 2.2, 95 % CI (1.0-4.7)], and those with up to one lifetime birth [AOR = 6.0, 95 % CI (2.0-18.1)] were likely to have moved to away from their communities for childbirth.

CONCLUSIONS

Despite most women who attended ANC doing so within their communities, we observed that majority chose to give birth outside their communities. Longer travel distances were more likely among AGYW, among shorter term community residents and where public health facilities were absent.

TRIAL REGISTRATION

PACTR201903906459874 (Retrospectively registered). https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5977 .

The impact of a health facility construction campaign on health service utilisation and outcomes: analysis of spatially linked survey and facility location data in Ethiopia

Background

Access to health facilities in many low-income and middle-income countries remains low, with a strong association between individuals’ distance to facilities and health outcomes. Yet plausibly causal estimates of the effects of facility construction programmes are rare. Starting in 2004, more than 2800 government health facilities were built in Ethiopia. This study estimates the impact of this programme on maternal health service utilisation and birth outcomes.

Methods

We analyse the impact of Ethiopia’s health centre construction programme on health service utilisation and outcomes, using a difference-in-difference design. We match facility opening years to child birth years in four rounds of Demographic and Health Surveys (DHS) using georeferenced data. We also use event study models to test for pre-trends in the outcomes of interest.

Results

Opening of new health facilities within 5 km increases facility delivery by 7.2 percentage points (95% CI 5.2 to 9.1) and antenatal care by 0.38 visits (95% CI 0.24 to 0.52). It is not significantly associated with changes in caesarean section births or neonatal mortality. Opening of district hospitals increases facility delivery by 18.2 percentage points (95% CI 12.7 to 23.7), and caesarean section births by 6.8 percentage points (95% CI 2.5 to 11.2), but is not associated with reduction of neonatal mortality.

Conclusions

Ethiopia’s facility construction program improved access to antenatal and delivery care. However, there was no detectable association between facility construction and neonatal mortality. Increased access to care must be combined with health system quality improvements and broader social development initiatives to sustainably improve health outcomes.

Women's experiences and satisfaction with maternal referral service in Northern Ghana: A qualitative inquiry

OBJECTIVE

To gain insights and improve existing referral structures with maternity care in Northern region of Ghana, this study explored the referral experiences and satisfaction of women.

RESEARCH DESIGN

Twenty women referred to the Tamale Teaching Hospital for maternal health conditions were interviewed along with three husdands of these women between January and April 2020. An interview guide was used in individual face-to-face semi-structured interviews. The transcripts were inductively coded using content analysis. The study was guided by the three delays model and the availability, accessibility, acceptability and quality framework.

FINDINGS

The study revealed seven key themes. These are women's involvement in referral decision; available health workers and care at the first facility; inadequate transportation; communication between facilities; quality of care at the receiving hospital; worth the time and money; and women's companions during referral. While several women acknowledged and appreciated the care and emotional support they received in the hospitals they first presented to, some women reported poor attitudes of healthcare providers. Most women acknowledged that there was no communication between the facilities for the referral. A woman's socioeconomic status appeared to determine the respect and support she received from healthcare providers.

KEY CONCLUSIONS

To ensure a responsive and efficient referral service, the central government of Ghana should commit to ensuring that each district hospital has at least one ambulance for effective emergency transportation. Career progression opportunities need to be explored for health workers in northern Ghana to attract and retain more professionals. To prevent abuse and ensure empathetic and supportive care, testimonial videos may help health providers to assess the services they provide to women. During referral, inter-facility communication can be strengthened through effective supervision and dedicated mobile phones for communication between health facilities.

A qualitative study of the maternal health information-seeking behaviour of women of reproductive age in Mpwapwa district, Tanzania

Background

Active engagement in seeking maternal health information among women of reproductive age is vital in promoting positive health‐seeking behaviour and improving maternal health outcomes.

Objective

This study aimed to explore maternal health information‐seeking behaviour of women of reproductive age in a rural Tanzania.

Methods

Using a qualitative research approach, the study held eight focus group discussions to collect data from a group of purposively selected women respondents. Data were analysed through thematic analysis.

Results

Women need a range of maternal health information for their informed health decision making. However, while they indicated the need to seek that information from professional health providers, they received most of it from non‐professional and informal sources, including community health workers, traditional birth attendants and their family members. The use of these sources is attributed to, among other factors, unavailability of health facilities and limited access to professional health care.

Conclusion

Access to relevant and reliable maternal health information is essential in creating awareness and empowering women to make informed decisions about their reproductive health. Women’s use of informal sources to meet their various information needs increases the chances of receiving unreliable information that may result in coming up with poor decisions making.

Magnitude and trends in socio-economic and geographic inequality in access to birth by cesarean section in Tanzania: evidence from five rounds of Tanzania demographic and health surveys (1996-2015)

Background

Majority of maternal deaths are avoidable through quality obstetric care such as Cesarean Section (CS). However, in low-and middle-income countries, many women are still dying due to lack of obstetric services. Tanzania is one of the African countries where maternal mortality is high. However, there is paucity of evidence related to the magnitude and trends of disparities in CS utilization in the country. This study examined both the magnitude and trends in socio-economic and geographic inequalities in access to birth by CS.

Methods

Data were extracted from the Tanzania Demographic and Health Surveys (TDHSs) (1996–2015) and analyzed using the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) software. First, access to birth by CS was disaggregated by four equity stratifiers: wealth index, education, residence and region. Second, we measured the inequality through summary measures, namely Difference (D), Ratio (R), Slope Index of Inequality (SII) and Relative Index of Inequality (RII). A 95% confidence interval was constructed for point estimates to measure statistical significance.

Results

The results showed variations in access to birth by CS across socioeconomic, urban-rural and regional subgroups in Tanzania from 1996 to 2015. Among the poorest subgroups, there was a 1.38 percentage points increase in CS coverage between 1996 and 2015 whereas approximately 11 percentage points increase was found among the richest subgroups within same period of time. The coverage of CS increased by nearly 1 percentage point, 3 percentage points and 9 percentage points among non-educated, those who had primary education and secondary or higher education, respectively over the last 19 years. The increase in coverage among rural residents was 2 percentage points and nearly 8 percentage points among urban residents over the last 19 years. Substantial disparity in CS coverage was recorded in all the studied surveys. For instance, in the most recent survey, pro-rich (RII = 15.55, 95% UI; 10.44, 20.66, SII = 15.8, 95% UI; 13.70, 17.91), pro-educated (RII = 13.71, 95% UI; 9.04, 18.38, SII = 16.04, 95% UI; 13.58, 18.49), pro-urban (R = 3.18, 95% UI; 2.36, 3.99), and subnational (D = 16.25, 95% UI; 10.02, 22.48) absolute and relative inequalities were observed.

Conclusion

The findings showed that over the last 19 years, women who were uneducated, poorest/poor, living in rural settings and from regions such as Zanzibar South, appeared to utilize CS services less in Tanzania. Therefore, such subpopulations need to be the central focus of policies and programmes implemmentation to improve CS services coverage and enhance equity-based CS services utilization.

Assessing the impact of mentorship on nurses' and midwives' knowledge and self-efficacy in managing postpartum hemorrhage

Background Despite medical technology advancement, postpartum hemorrhage remains the top universal cause of maternal mortality. Factors note the inconsistency in recognition and timely treatment of women experiencing it, which suggests healthcare professionals' mentorship about postpartum hemorrhage. Methods The study recruited 141 nurses and midwives and used instruments adapted to knowledge and self-efficacy to assess the impact of mentorship on nurses' and midwives' knowledge and self-efficacy in managing postpartum hemorrhage. Results There was an increase in knowledge from 68% prior to mentorship up to 87% and self-efficacy from 6.9 to 9.5 average score out of 10. Knowledge and self-efficacy correlated moderately positive at pre-mentorship (r=0.214) and strongly positive at post-mentorship (r=0.585). The number of mentorship visits attended was associated with post-mentorship knowledge scores (r=0.539) and post-mentorship self-efficacy (r=0.623). Conclusions Mentorship about management of postpartum hemorrhage increases nurses' and midwives' knowledge and self-efficacy in managing postpartum hemorrhage.

Postpartum Maternal Mood Among Hadza Foragers of Tanzania: A Mixed Methods Approach

Infant and maternal mortality rates are among the highest in the world in low and middle-income countries where postpartum depression impacts at least one in five women. Currently, there is a dearth of data on maternal mood and infant health outcomes in small-scale non-industrial populations from such countries, particularly during the postnatal period. Here, we present the first investigation of postpartum maternal mood among a foraging population, the Hadza of Tanzania. We administered the Edinburgh Postnatal Depression Scale (EPDS) to twenty-three women, all with infants under the age of 12 months. Semi-structured interviews on happiness and unhappiness during the post-partum period served as a validity cross-check for the EPDS. The combined results of the EPDS surveys and the interview responses suggest that a high proportion of Hadza women experience significant mood disturbances following birth and that postpartum unhappiness is associated with self-reports of pain, anxiety, and disturbed sleep patterns. These findings suggest that many of the mothers in our sample are experiencing post-partum unhappiness at levels similar to or higher than those reported for low to middle income countries in general, including Tanzania. These data are critical for improving our understanding of the etiologies of postpartum mood disturbances cross-culturally.

Is distance associated with tuberculosis treatment outcomes? A retrospective cohort study in Kampala, Uganda

Background

Challenges accessing nearby health facilities may be a barrier to initiating and completing tuberculosis (TB) treatment. We aimed to evaluate whether distance from residence to health facility chosen for treatment is associated with TB treatment outcomes.

Methods

We conducted a retrospective cohort study of all patients initiating TB treatment at six health facilities in Kampala from 2014 to 2016. We investigated associations between distance to treating facility and unfavorable TB treatment outcomes (death, loss to follow up, or treatment failure) using multivariable Poisson regression.

Results

Unfavorable treatment outcomes occurred in 20% (339/1691) of TB patients. The adjusted relative risk (aRR) for unfavorable treatment outcomes (compared to treatment success) was 0.87 (95% confidence interval [CI] 0.70, 1.07) for patients living ≥2 km from the facility compared to those living closer. When we separately compared each type of unfavorable treatment outcome to favorable outcomes, those living ≥2 km from the facility had increased risk of death (aRR 1.42 [95%CI 0.99, 2.03]) but decreased risk for loss to follow-up (aRR 0.57 [95%CI 0.41, 0.78]) than those living within 2 km.

Conclusions

Distance from home residence to TB treatment facility is associated with increased risk of death but decreased risk of loss to follow up. Those who seek care further from home may have advanced disease, but once enrolled may be more likely to remain in treatment.

Warren C. Clinical presentation and outcomes of pre-eclampsia and eclampsia at a national hospital, Kenya: A retrospective cohort study

BACKGROUND

Hypertensive disorders in pregnancy including pre-eclampsia are associated with maternal and newborn mortality and morbidity. Early detection is vital for effective treatment and management of pre-eclampsia. This study examines and compares the clinical presentation and outcomes between early- and late-onset pre-eclampsia over a two year period.

METHODS

A retrospective cohort study design which examines socio-demographic characteristics, treatment, outcomes, and fetal and maternal complications among women with early onset of pre-eclampsia (EO-PE) and late onset of pre-eclampsia (LO-PE). De-identified records of women who attended antenatal, intrapartum and postnatal care services and experienced pre-eclampsia at Kenyatta National teaching and referral hospital were reviewed. We used chi square, t-test, and calculated odds ratio to determine any significant differences between the EO-PE and LO-PE cohorts.

RESULTS

Out of 620 pre-eclamptic and eclamptic patients' records analyzed; 44 percent (n = 273) exhibited EO-PE, while 56 percent had late onset. Women with EO-PE compared to LO-PE had greater odds of adverse maternal and perinatal outcomes including hemolysis elevated liver enzymes and low platelets (HELLP) syndrome (OR: 4.3; CI 2.0-10.2; p<0.001), renal dysfunction (OR; 1.7; CI 0.7-4.1; p = 0.192), stillbirth (OR = 4.9; CI 3.1-8.1; p<0.001), and neonatal death (OR: 8.5; CI 3.8-21.3; p<0.001). EO-PE was also associated with higher odds of prolonged maternal hospitalization, beyond seven days (OR = 5.8; CI 3.9-8.4; p<0.001), and antepartum hemorrhage (OR = 5.8; CI 1.1-56.4; p<0.001). Neonates born after early onset of pre-eclampsia had increased odds of respiratory distress (OR = 17.0; CI 9.0-32.3, p<0.001) and birth asphyxia (OR: 1.9; CI 0.7-4.8; p = 0.142).

CONCLUSIONS

The profiles and outcomes of women with EO-PE (compared to late onset) suggest that seriousness of morbidity increases with earlier onset. To reduce adverse neonatal and maternal outcomes, it is critical to identify, manage, referral and closely follow-up pregnant women with pre-eclampsia throughout the pregnancy continuum.

ETHICAL APPROVAL

This study protocol was approved by Population Council's research ethics Institutional Review Board, Protocol 813, and KNH-UoN Ethics and Research Committee, Protocol 293/06/2017.

Predicted effect of regionalised delivery care on neonatal mortality, utilisation, financial risk, and patient utility in Malawi: an agent-based modelling analysis

BACKGROUND

Health-care regionalisation, in which selected services are concentrated in higher-level facilities, has successfully improved the quality of complex medical care. However, the effectiveness of this strategy in routine maternal care is unknown. Malawi has established a national goal of halving its neonatal mortality by 2030. In this study, we aimed to assess the effect of obstetric service regionalisation in pregnant women and their newborn babies in Malawi.

METHODS

In this analysis, we assessed regionalisation through the use of an agent-based simulation model. We used a previously estimated utilisation function, incorporating both patient-specific and health-facility-specific characteristics, to inform patient choice. The model was validated against known utilisation patterns in Malawi. Four regionalisation scenarios were compared with the status quo: scenario 1 restricted deliveries to facilities currently capable of providing caesarean sections; scenario 2 had the same restrictions as scenario 1, but with selected facilities upgraded to provide caesarean sections; scenario 3 restricted delivery to facilities that provided five or more basic emergency obstetric and neonatal care services in the preceding 3 months; and scenario 4 had the same restrictions as scenario 3, but with selected facilities upgraded to provide at least five basic emergency obstetric and neonatal care services. We assessed neonatal mortality, utilisation, travel distance, median out-of-pocket expenditure, and proportion of women facing catastrophic expenditure. The effects of upgrading the obstetric readiness of all facilities, of removing all user fees, and of upgrading without restriction were considered in scenario analyses. Heterogeneity and parameter uncertainty were incorporated to create 95% posterior credible intervals (PCIs).

FINDINGS

Scenarios restricting women to give birth in facilities with caesarean section capabilities reduced neonatal mortality by 11·4 deaths per 1000 livebirths (scenario 1; 95% PCI 9·8-13·1) and 11·6 deaths per 1000 livebirths (scenario 2; 10·2-13·1), whereas scenarios restricting women to facilities that provided five or more basic emergency obstetric and neonatal care services did not affect neonatal mortality. Similarly, the caesarean section rate in Malawi, which is 4·6% under the status quo, was predicted to rise significantly in scenario 1 (14·7%, 95% PCI 14·5-14·9; p<0·0001) and scenario 2 (10·4%, 10·2-10·6; p<0·0001), but not in scenarios 3 and 4. Women were required to travel longer distances in scenario 1 (increase of 7·2 km, 95% PCI 4·5-9·9) and in scenario 2 (4·4 km, 1·5-7·2) than in the status quo (p<0·0001). Out-of-pocket costs tripled (p<0·0001; status quo vs scenario 1 and scenario 2), and the risk of catastrophic expenditure significantly increased from a baseline of 6·4% (95% PCI 6·1-6·6) to 14·7% (14·5-14·9) in scenario 1 and 11·3% (11·0-11·5) in scenario 2. This increase was especially pronounced among the poor (p<0·0001; status quo vs scenario 1 and scenario 2).

INTERPRETATION

Policies restricting women to give birth in facilities with caesarean section capabilities is likely to result in significant decreases in neonatal mortality and might allow Malawi to meet its goal of halving its neonatal mortality by 2030. However, this improvement comes at the cost of increased distances to care and worsening financial risks among women.

FUNDING

Bill & Melinda Gates Foundation, Damon Runyon Cancer Research Foundation.

Evaluation of emergency obstetric and neonatal care services in Kumba Health District, Southwest region, Cameroon (2011-2014): a before-after study

Background

There is uncertainty regarding the status of emergency obstetric and neonatal care (EmONC) in the Cameroonian context where maternal and neonatal mortality are persistently high. This study sought to evaluate the coverage, functionality and quality of EmONC services in Kumba health district (KHD), the largest health district in Southwest Cameroon..

Methods

A retrospective study of routine EmONC data for the periods 1 January 2011 to 31 December 2012 (when EmONC was being introduced) and 1 January 2013 to 31 December 2014 (when EmONC was fully instituted) was conducted. Coverage, functionality and quality of EmONC services were graded as per United Nations (UN) standards. Data was analysed using Epi-Info version 7 statistical software.

Results

Among the 31 health facilities in KHD, 12 (39%) had been delivering EmONC services. Three (25%) of these were geographically inaccessible Among the 9 facilities that were assessed, 4 facilities (44%) performed designated signal functions, with 2 being comprehensive (CEmONC) and 2 basic (BEmONC). These exceeded the required minimum of 2.8 EmONC facilities/500000, 0.6 CEmONC facilities/500000 and 2.2 BEmONC facilities/500000, with reference to an estimated KHD population of 265,071. The signal functions that were least likely to be performed were neonatal resuscitation, manual evacuation of retained products and use of anticonvulsants. In 2011–2012, the facilities performed 35% of expected deliveries. This dropped to 28% in 2013–2014. Caesarean sections as a proportion of expected deliveries remained very low: 1.5% in 2010–2011 and 3.6% in 2013–2014. In 2011–2012, met needs were 6.8% and increased to 7.3% in 2013–2014. Direct obstetric fatality rates increased from 8 to 11% (p = 0.64). Intrapartum and very early neonatal deaths increased from 4.% to 7 (p = 0.89).

Conclusion

Major gaps were observed in the performance of signal functions as well as the quality and utilization of EmONC. While the results of this study seem to indicate the need to sustainably scale up the utilization of quality EmONC, the interpretations of our findings require consideration of improvements in reporting of mortality data associated with the introduction of EmONC as well as dynamics in country-specific maternal health policies and the potential influence of these policies on EmONC indicators.

Are perceived barriers to accessing health care associated with inadequate antenatal care visits among women of reproductive age in Rwanda?

Background

Maternal and child mortality remain a global health concern despite different interventions that have been implemented to address this issue. Adequate antenatal care (ANC) is crucial in reducing maternal and neonatal morbidity and mortality. However, in Rwanda, there is still suboptimal utilization of ANC services. This study aims to assess the relationship between perceived barriers to accessing health care and inadequate ANC visits among women of reproductive age in Rwanda.

Methods

This study is cross-sectional using secondary data from the 2014–15 Rwanda demographic and health survey (RDHS). The study included 5876 women aged 15–49 years, and the primary outcome of the investigation was inadequate ANC visits defined as delayed first ANC visit and non-completion of at least four recommended visits during the pregnancy period. The primary exposure was perceived barriers to accessing health care, operationalized using the following 4 variables: distance to the health facility, getting money for treatment, not wanting to go alone and getting permission to go for treatment. A survey-weighted multivariable logistic regression analysis and backward elimination method based on Akaike information criterion (AIC) was used to select the final model. We conducted a number of sensitivity analyses using stratified and weighting propensity score methods and investigated the relationship between the outcome and each barrier to care separately.

Results

Of 5, 876 women included in the analysis, 53% (3132) aged 20 to 34 years, and 44% (2640) were in the lowest wealth index. Overall, 64% (2375) of women who perceived to have barriers to health care had inadequate ANC visits. In multivariable analysis, women who perceived to have barriers to health care had higher odds of having inadequate ANC visits (OR: 1.14; 95% CI: 0.99, 1.31). However, the association was borderline statistically significant. The findings from sensitivity analyses were consistent with the main analysis results.

Conclusion

The study suggests a positive association between perceived barriers to health care access and inadequate ANC visits. The findings speak to a need for interventions that focus on improving access to health care in Rwanda to increase uptake of ANC services.

Maternal mortality by socio-demographic characteristics and cause of death in South Africa: 2007-2015

Background

South Africa’s maternal mortality ratio remains high although it has substantially declined in the past few years. Numerous studies undertaken in South Africa on maternal mortality have not paid much attention to how the causes are distributed in different socio-demographic groups. This study assesses and analyses the causes of maternal mortality according to sociodemographic factors in South Africa.

Methods

The causes of maternal deaths were assessed with respect to age, province, place of death, occupation, education and marital status. Data were obtained from the vital registration database of Statistics South Africa. About 14,892 maternal deaths of women from 9 to 55 years of age were analysed using frequency tables, cross-tabulations and logistic regression. Maternal mortality ratio (MMR), by year, age group, and province for the years 2007–2015 was calculated.

Results

The 2007–2015 MMR was 139.3 deaths per 100,000 live births (10,687,687 total live births). The year 2009 had the highest MMR during this period. Specific province MMR for three triennia (2007–2009; 2010–2012; 2013–2015) shows that the Free State province had the highest MMR (297.9/100000 live births; 214.6/100000 live births; 159/100000 live births) throughout this period. MMR increased with age. Although the contribution of the direct causes of death (10603) was more than double the contribution of indirect causes (4289) maternal mortality showed a steady decline during this period.

Conclusions

The study shows evidence of variations in the causes of death among different socio-demographic subgroups. These variations indicate that more attention has to be given to the role played by socio-demographic factors in maternal mortality.

Maternal healthcare services use in Mwanza Region, Tanzania: a cross-sectional baseline survey

Background

Improving maternal health by reducing maternal mortality/morbidity relates to Goal 3 of the Sustainable Development Goals. Achieving this goal is supported by antenatal care (ANC), health facility delivery, and postpartum care. This study aimed to understand levels of use and correlates of uptake of maternal healthcare services among women of reproductive age (15–49 years) in Mwanza Region, Tanzania.

Methods

A cross-sectional multi-stage sampling household survey was conducted to obtain data from 1476 households in six districts of Mwanza Region. Data for the 409 women who delivered in the 2 years before the survey were analyzed for three outcomes: four or more ANC visits (ANC4+), health facility delivery, and postpartum visits. Factors associated with the three outcomes were determined using generalized estimating equations to account for clustering at the district level while adjusting for all variables.

Results

Of the 409 eligible women, 58.2% attended ANC4+, 76.8% delivered in a health facility, and 43.5% attended a postpartum clinic. Women from peri-urban, island, and rural regions were less likely to have completed ANC4+ or health facility delivery compared with urban women. Education and early first antenatal visit were associated with ANC4+ and health facility delivery. Mothers from peri-urban areas and those who with health facility delivery were more likely to attend postpartum check-ups.

Conclusion

Use of ANC services in early pregnancy influences the number of ANC visits, leading to higher uptake of ANC4+ and health facility delivery. Postpartum check-ups for mothers and newborns are associated with health facility delivery. Encouraging early initiation of ANC visits may increase the uptake of maternal healthcare services.

Health Care Financing Systems and Their Effectiveness: An Empirical Study of OECD Countries

Background: The primary aim of the research in the present study was to determine the effectiveness of health care in classifying health care financing systems from a sample of OECD (Organisation for Economic Co-operation and Development) countries (2012–2017). This objective was achieved through several stages of analysis, which aimed to assess the relations between and relation diversity in selected variables, determining the effectiveness of health care and the health expenditure of health care financing systems. The greatest emphasis was placed on the differences between health care financing systems that were due to the impact of health expenditure on selected health outputs, such as life expectancy at birth, perceived health status, the health care index, deaths from acute myocardial infarction and diabetes mellitus. Methods: Methods such as descriptive analysis, effect analysis (η²), binomial logistic regression analysis, linear regression analysis, continuity analysis (ρ) and correspondence analysis, were used to meet the above objectives. Results: Based on several stages of statistical processing, it was found that there are deviations in several of the relations between different health care funding systems in terms of their predisposition to certain areas of health outcomes. Thus, where one system proves ineffective (or its effectiveness is questionable), another system (or systems) appears to be effective. From a correspondence analysis that compared the funding system and other outputs (converted to quartiles), it was found that a national health system, covering the country as a whole, and multiple insurance funds or companies would be more effective systems. Conclusions: Based on the findings, it was concluded that, in analyzing issues related to health care and its effectiveness, it is appropriate to take into account the funding system (at least to verify the significance of how research premises affect the systems); otherwise, the results may be distorted.

Armed conflict and maternal mortality: A micro-level analysis of sub-Saharan Africa, 1989-2013

There is existing country-level evidence that countries with more severe armed conflict tend to have higher Maternal Mortality Rates (MMR). However, during armed conflict, the actual fighting is usually confined to a limited area within a country, affecting a subset of the population. Hence, studying the link between country-level armed conflict and MMR may involve ecological fallacies. We provide a more direct, nuanced test of whether local exposure to armed conflict impacts maternal mortality, building on the so-called "sisterhood method". We combine geo-coded data on different types of violent events from the Uppsala Conflict Data Program with geo-referenced survey data from the Demographic and Health Surveys (DHS) on respondents' reports on sisters dying during pregnancy, childbirth, or the puerperium. Our sample covers 1,335,161 adult sisters aged 12-45 by 539,764 female respondents in 30 countries in sub-Saharan Africa. Rather than aggregating the deaths of sisters to generate a maternal mortality ratio, we analyze the sisters' deaths at the individual level. We use a sister fixed-effects analysis to estimate the impact of recent organized violence events within a radius of 50 km of the home of each respondent on the likelihood that her sister dies during pregnancy, childbirth, or the puerperium. Our results show that local exposure to armed conflict events indeed increases the risk of maternal deaths. Exploring potential moderators, we find larger differences in rural areas but also in richer and more educated areas.

Methodological Challenges When Studying Distance to Care as an Exposure in Health Research

Distance to care is a common exposure and proposed instrumental variable in health research, but it is vulnerable to violations of fundamental identifiability conditions for causal inference. We used data collected from the Botswana Birth Outcomes Surveillance study between 2014 and 2016 to outline 4 challenges and potential biases when using distance to care as an exposure and as a proposed instrument: selection bias, unmeasured confounding, lack of sufficiently well-defined interventions, and measurement error. We describe how these issues can arise, and we propose sensitivity analyses for estimating the degree of bias.

Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials

BACKGROUND

Maternal and perinatal mortality are still unacceptably high in many countries despite steep increases in facility birth. The evidence that childbirth in facilities reduces mortality is weak, mainly because of the scarcity of robust study designs and data. We aimed to assess this link by quantifying the influence of major determinants of facility birth (cluster-level facility birth, wealth, education, and distance to childbirth care) on several mortality outcomes, while also considering quality of care.

METHODS

Our study is a secondary analysis of surveillance data on 119 244 pregnancies from two large population-based cluster-randomised controlled trials in Brong Ahafo, Ghana. In addition, we specifically collected data to assess quality of care at all 64 childbirth facilities in the study area. Outcomes were direct maternal mortality, perinatal mortality, first-day and early neonatal mortality, and antepartum and intrapartum stillbirth. We calculated cluster-level facility birth as the percentage of facility births in a woman's village over the preceding 2 years, and we computed distances from women's regular residence to health facilities in a geospatial database. Associations between determinants of facility birth and mortality outcomes were assessed in crude and multivariable multilevel logistic regression models. We stratified perinatal mortality effects by three policy periods, using April 1, 2005, and July 1, 2008, as cutoff points, when delivery-fee exemption and free health insurance were introduced in Ghana. These policies increased facility birth and potentially reduced quality of care.

FINDINGS

Higher proportions of facility births in a cluster were not linked to reductions in any of the mortality outcomes. In women who were wealthier, facility births were much more common than in those who were poorer, but mortality was not lower among them or their babies. Women with higher education had lower mortality risks than less-educated women, except first-day and early neonatal mortality. A substantially higher proportion of women living in areas closer to childbirth facilities had facility births and caesarean sections than women living further from childbirth facilities, but mortality risks were not lower despite this increased service use. Among women who lived in areas closer to facilities offering comprehensive emergency obstetric care (CEmOC), emergency newborn care, or high-quality routine care, or to facilities that had providers with satisfactory competence, we found a lower risk of intrapartum stillbirth (14·2 per 1000 deliveries at >20 km from a CEmOC facility vs 10·4 per 1000 deliveries at ≤1 km; odds ratio [OR] 1·13, 95% CI 1·06-1·21) and of composite mortality outcomes than among women living in areas where these services were further away. Protective effects of facility birth were restricted to the two earlier policy periods (from June 1, 2003, to June 30, 2008), whereas there was evidence for higher perinatal mortality with increasing wealth (OR 1·09, 1·03-1·14) and lower perinatal mortality with increasing distance from childbirth facilities (OR 0·93, 0·89-0·98) after free health insurance was introduced in July 1, 2008.

INTERPRETATION

Facility birth does not necessarily convey a survival benefit for women or babies and should only be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safe-guarding uncomplicated births.

FUNDING

The Baden-Württemberg Foundation, the Daimler and Benz Foundation, the European Social Fund and Ministry of Science, Research, and the Arts Baden-Württemberg, WHO, US Agency for International Development, Save the Children, the Bill & Melinda Gates Foundation, and the UK Department for International Development.

Obstetric admissions and outcomes in an intensive care unit in Malawi

BACKGROUND

Despite international commitment to Millennium Development Goal 5, maternal mortality remains high in low- and middle-income countries (LMICs) of sub-Saharan Africa. This is in part due to infrastructure gaps, including availability of intensive care units (ICUs). We sought to use obstetric ICU utilization as a marker of severe maternal morbidity and provide an initial characterization of its relationship with in-hospital mortality.

METHODS

A prospective observational cohort study of all obstetric subjects admitted to the ICU of Kamuzu Central Hospital in Malawi from September 2016 to March 2018. We reviewed charts at the time of ICU admission to assess the indication for admission, clinical characteristics and laboratory values. Subjects were followed until death or discharge. The primary outcome was in-hospital mortality.

RESULTS

One-hundred-and-five obstetric patients were admitted to the study ICU (23% of all admissions). The median age was 26 years. The majority (79%) had undergone recent surgery; 40 (52%) an abdominal postnatal or cesarean hysterectomy and 31 (40%) a cesarean delivery without hysterectomy. Ninety-five percent required mechanical ventilation and 48% required vasopressors. Overall in-hospital mortality was 49%.

CONCLUSIONS

The proportion of obstetric subjects admitted to the ICU in Malawi is nearly 1 in 4, which exceeds that found in high-income countries by orders of magnitude. Intensive care unit admission was associated with high mortality in this population. Investments in improving infrastructure and care gaps may include addressing available ICU bed and blood-banking needs, and increasing the number of providers trained in managing critical illness among obstetric patients.