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Grabert BK, Speizer IS, Domino ME, Frerichs L, Corneli A, Fried BJ. Couple communication and contraception use in urban Senegal. SAGE Open Med 2021; 9:20503121211023378. [PMID: 34158943 PMCID: PMC8182225 DOI: 10.1177/20503121211023378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 05/19/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives: Couple communication about family planning has been shown to increase uptake
of contraception. However, couple communication is often measured based
solely on one partner’s report of communication. This research investigates
the influence of couple-reported communication about family planning on
current and future use of contraception using couple-level data. Methods: We used baseline data from the Measurement, Learning, and Evaluation (MLE)
project collected through household surveys in 2011 from a cross-sectional
representative sample of women and men in urban Senegal to conduct secondary
data analysis. We used multivariable logit models to estimate the average
marginal effects of couple communication about family planning on current
contraception use and future intention to use contraception. Results: Couple communication about family planning reported by both partners was
significantly associated with an increased likelihood of current use of
contraception and with future intention to use contraception among
non-contracepting couples. Couples where one partner reported discussing
family planning had a 25% point greater likelihood of current contraception
use than couples where neither partner reported discussing, while couples
where both partners reported discussing family planning had a 56% point
greater likelihood of current contraception use, representing more than
twice the effect size. Among couples not using contraception, couples where
one partner reported discussing family planning had a 15% point greater
likelihood of future intention to use contraception than couples where
neither partner reported discussing, while couples where both partners
reported discussing family planning had a 38% point greater likelihood of
future intention to use contraception. Conclusion: These findings underscore the importance of the inclusion of both partners in
family planning programs to increase communication about contraception and
highlight the need for future research using couple-level data, measures,
and analysis.
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Affiliation(s)
- Brigid K Grabert
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ilene S Speizer
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA.,Carolina Population Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Marisa Elena Domino
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA.,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Leah Frerichs
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Amy Corneli
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Bruce J Fried
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
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Uneke CJ, Sombie I, Uro-Chukwu HC, Johnson E. Using equitable impact sensitive tool (EQUIST) to promote implementation of evidence informed policymaking to improve maternal and child health outcomes: a focus on six West African Countries. Global Health 2018; 14:104. [PMID: 30400931 PMCID: PMC6219200 DOI: 10.1186/s12992-018-0422-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 10/12/2018] [Indexed: 01/05/2023] Open
Abstract
Background United Nations Children’s Fund (UNICEF) designed EQUitable Impact Sensitive Tool (EQUIST) to enable global health community address the issue of equity in maternal, newborn and child health (MNCH) and minimize health disparities between the most marginalized population and the better-off. The purpose of this study was to use EQUIST to provide reliable evidence, based on demographic health surveys (DHS) on cost–effectiveness and equitable impact of interventions that can be implemented to improve MNCH outcomes in Benin, Burkina Faso, Ghana, Mali, Nigeria and Senegal. Methods Using the latest available DHS data sets, we conducted EQUIST Situation Analysis of maternal and child health outcomes in the six countries by sub-national categorization, wealth and by residence. We then identified the poorest population class within each country with the highest maternal and child mortality and performed EQUIST Scenario Analysis of this population to identify intervention package, bottlenecks and strategies to address them, cost of the intervention and strategies as well as the number of deaths avertible. Results Under-five mortality was highest in Atlantique (Benin), Sahel (Burkina Faso), Northern (Ghana), Sikasso (Mali), North-West (Nigeria), and Diourbel (Senegal). The number of under-five deaths was considerably higher among the poorest and rural population. Neonatal causes, malaria, pneumonia and diarrhoea were responsible for most of the under-five deaths. Ante-partum, intra-partum, and post-partum haemorrhages, and hypertensive disorder, were responsible for highest maternal deaths. The national average for improved water source was highest in Ghana (82%). Insecticide treated nets ownership percentage national average was highest in Benin (73%). Delivery by skilled professional is capable of averting the highest number of under-five and maternal deaths in the six countries. Redeployment/relocation of existing staff was the strategy with highest costs in Burkina Faso, Nigeria and Senegal. Ghana recorded the least cost per capita ($0.39) while the highest cost per capita was recorded in Benin ($4.0). Conclusion EQUIST highlights the most vulnerable and deprived children and women needing urgent health interventions as a matter of priority. It will continue to serve as a tool for maximizing the number of lives saved; decreasing health disparities and improving overall cost effectiveness. Electronic supplementary material The online version of this article (10.1186/s12992-018-0422-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chigozie Jesse Uneke
- African Institute for Health Policy and Health Systems, Ebonyi State University, CAS Campus, Abakaliki, PMB 053, Nigeria.
| | - Issiaka Sombie
- Organisation Ouest Africaine de la Santé, 175, Avenue Ouezzin Coulibaly, Bobo Dioulasso 01, 01 BP 153, Burkina Faso
| | - Henry Chukwuemeka Uro-Chukwu
- African Institute for Health Policy and Health Systems, Ebonyi State University, CAS Campus, Abakaliki, PMB 053, Nigeria
| | - Ermel Johnson
- Organisation Ouest Africaine de la Santé, 175, Avenue Ouezzin Coulibaly, Bobo Dioulasso 01, 01 BP 153, Burkina Faso
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Do M, Wang W, Hembling J, Ametepi P. Quality of antenatal care and client satisfaction in Kenya and Namibia. Int J Qual Health Care 2017; 29:183-193. [PMID: 28453821 DOI: 10.1093/intqhc/mzx001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 01/10/2017] [Indexed: 11/12/2022] Open
Abstract
Objective Despite much progress in maternal health service coverage, the quality of care has not seen parallel improvement. This study assessed the quality of antenatal care (ANC), an entry point to the health system for many women. Design The study used data from recent Service Provision Assessment (SPA) surveys of nationally representative health facilities in Kenya and Namibia. Setting Kenya and Namibia represent the situation in much of sub-Saharan Africa, where ANC is relatively common but maternal mortality remains high. Participants The SPA comprised an inventory of health facilities that provided ANC, interviews with ANC providers and clients, and observations of service delivery. Interventions Not applicable. Main Outcome Measures Quality was measured in terms of structure and process of service provision, and client satisfaction as the outcome of service provision. Results Wide variations in structural and process attributes of quality of care existed in both Kenya and Namibia; however, better structural quality did not translate to better service delivery process or greater client satisfaction. Long waiting time was a common problem and was generally more serious in hospitals and health centers than in clinics and smaller facilities; it was consistently associated with lower client satisfaction. The study also indicates that the provider's technical preparedness may not be sufficient to provide good-quality services and to ensure client satisfaction. Conclusions Findings highlight important program implications, including improving ANC services and promoting their use at health clinics and lower-level facilities, and ensuring that available supplies and equipment are used for service provision.
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Affiliation(s)
- Mai Do
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Wenjuan Wang
- ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA
| | - John Hembling
- Catholic Relief Services, 228 W. Lexington St., Baltimore, MD 21201, USA
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Uribe-Leitz T, Jaramillo J, Maurer L, Fu R, Esquivel MM, Gawande AA, Haynes AB, Weiser TG. Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data. LANCET GLOBAL HEALTH 2017; 4:e165-74. [PMID: 26916818 DOI: 10.1016/s2214-109x(15)00320-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/25/2015] [Accepted: 12/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety. METHODS We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates. FINDINGS From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs. INTERPRETATION All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care. FUNDING None.
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Affiliation(s)
| | | | - Lydia Maurer
- Stanford University School of Medicine, Stanford, CA, USA
| | - Rui Fu
- Management Science and Engineering, Stanford University, Stanford, CA, USA
| | | | - Atul A Gawande
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Alex B Haynes
- Ariadne Labs: a Joint Center for Health System Innovation, Boston, MA, USA; Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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Friedman HS, Liang M, Banks JL. Measuring the cost-effectiveness of midwife-led versus physician-led intrapartum teams in developing countries. ACTA ACUST UNITED AC 2015; 11:553-64. [PMID: 26258663 DOI: 10.2217/whe.15.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
International agencies have advocated scaling-up of midwifery resources as an important method for improving maternal health and reducing maternal mortality rates (MMR). The cost-effectiveness of midwife-led versus physician-led intrapartum care is an important consideration in the human resource planning required to reduce MMR. Studies suggest that midwife-led teams can achieve comparable effectiveness and outcomes using less medically intensive care compared with physician-led teams. In the absence of adequate medical cost data, decision makers should consider the substantially lower average costs for three main drivers: salaries, benefits and incentives (≥two-times lower); preservice training (three-times lower) and attrition (two-times lower) necessary to deliver intrapartum care at the level of midwife competencies. This suggests that scale-up of midwifery resources is a less expensive and more cost-effective way to reduce MMRs and could potentially increase access to skilled intrapartum care.
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Affiliation(s)
- Howard S Friedman
- United Nations Population Fund (UNFPA), Technical Division, 605 3rd Avenue, New York, NY 10158, USA
| | - Mengjia Liang
- United Nations Population Fund (UNFPA), Technical Division, 605 3rd Avenue, New York, NY 10158, USA
| | - Jamie L Banks
- Collaborative Health Advisors, LLC, Lincoln, MA, USA
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Chinkhumba J, De Allegri M, Muula AS, Robberstad B. Maternal and perinatal mortality by place of delivery in sub-Saharan Africa: a meta-analysis of population-based cohort studies. BMC Public Health 2014; 14:1014. [PMID: 25263746 PMCID: PMC4194414 DOI: 10.1186/1471-2458-14-1014] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 09/23/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Facility-based delivery has gained traction as a key strategy for reducing maternal and perinatal mortality in developing countries. However, robust evidence of impact of place of delivery on maternal and perinatal mortality is lacking. We aimed to estimate the risk of maternal and perinatal mortality by place of delivery in sub-Saharan Africa. METHODS We conducted a systematic review of population-based cohort studies reporting on risk of maternal or perinatal mortality at the individual level by place of delivery in sub-Saharan Africa. Newcastle-Ottawa Scale was used to assess study quality. Outcomes were summarized in pooled analyses using fixed and random effects models. We calculated attributable risk percentage reduction in mortality to estimate exposure effect. We report mortality ratios, crude odds ratios and associated 95% confidence intervals. RESULTS We found 9 population-based cohort studies: 6 reporting on perinatal and 3 on maternal mortality. The mean study quality score was 10 out of 15 points. Control for confounders varied between the studies. A total of 36,772 pregnancy episodes were included in the analyses. Overall, perinatal mortality is 21% higher for home compared to facility-based deliveries, but the difference is only significant when produced with a fixed effects model (OR 1.21, 95% CI: 1.02-1.46) and not when produced by a random effects model (OR 1.21, 95% CI: 0.79-1.84). Under best settings, up to 14 perinatal deaths might be averted per 1000 births if the women delivered at facilities instead of homes. We found significantly increased risk of maternal mortality for facility-based compared to home deliveries (OR 2.29, 95% CI: 1.58-3.31), precluding estimates of attributable risk fraction. CONCLUSION Evaluating the impact of facility-based delivery strategy on maternal and perinatal mortality using population-based studies is complicated by selection bias and poor control of confounders. Studies that pool data at an individual level may overcome some of these problems and provide better estimates of relative effectiveness of place of delivery in the region.
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Affiliation(s)
- Jobiba Chinkhumba
- />University of Malawi, College of Medicine, Private Bag 360, Chichiri, Blantyre 3 Malawi
- />University of Bergen, Center for International Health, Bergen, Norway
| | - Manuela De Allegri
- />Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Adamson S Muula
- />University of Malawi, College of Medicine, Private Bag 360, Chichiri, Blantyre 3 Malawi
| | - Bjarne Robberstad
- />University of Bergen, Center for International Health, Bergen, Norway
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Luexay P, Malinee L, Pisake L, Marie-Hélène BC. Maternal near-miss and mortality in Sayaboury Province, Lao PDR. BMC Public Health 2014; 14:945. [PMID: 25213771 PMCID: PMC4177158 DOI: 10.1186/1471-2458-14-945] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 09/05/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal near-miss (MNM) incidence is the indicator reflecting maternal healthcare services. This study aimed to determine the burden of maternal near-miss and maternal deaths in Sayaboury Province, Lao PDR. METHODS A descriptive study was done in a cohort of 1215 pregnant women, who had their last normal menstrual period (LMP) between 1 August and 31 December, 2010. WHO criteria for MNM were used to identify near-miss cases and maternal deaths during February-November 2011. Data of maternal characteristics, MNM, and maternal deaths were prospectively collected by primary health care workers in the villages under supervision of health staff in local health centers and by the head nurses of the gynecology-obstetric wards in the studied hospitals. Frequencies with 95% confidence intervals (CIs) were used to describe maternal near-misses and maternal deaths. RESULTS Overall, 92.5% of the 1215 pregnancies were delivered, 7.5% were aborted. Eleven women were identified as near-miss cases, giving a maternal near miss (MNM) ratio of 9.8 (95% CI: 4.9-17.5)/1,000 live births. With two maternal deaths, the maternal mortality ratio (MMR) was 178 (95% CI: 50-650)/100,000 live births. Together, these constituted 13 cases of severe maternal outcome (SMO) and given the SMO ratio of 11.6 (95% CI: 6.2-19.8)/1,000 live births. CONCLUSION The study shows a surprisingly low MNM ratio and MMR in Sayaboury Province, Lao PDR. Generalization of the results is limited by problems in applying standard criteria for the identification of near-misses in the communities and local hospitals. However, the findings are considered to have important implications for the improvement of maternal health services in low resource settings, e.g. to obtain valid and reliable maternal near miss and maternal deaths for the whole country.
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Affiliation(s)
| | - Laopaiboon Malinee
- Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, 123 Mittapharp Road, 40002 Muaeng district, Khon Kaen, Thailand.
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Merali HS, Lipsitz S, Hevelone N, Gawande AA, Lashoher A, Agrawal P, Spector J. Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. BMC Pregnancy Childbirth 2014; 14:280. [PMID: 25129069 PMCID: PMC4143551 DOI: 10.1186/1471-2393-14-280] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 08/05/2014] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Audits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries. METHODS We performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews. RESULTS Thirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified. CONCLUSIONS Audits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five.
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Affiliation(s)
- Hasan S Merali
- The Hospital for Sick Children, 555 University Avenue, Toronto ON M5G 1X8, Canada.
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Fuhr DC, Calvert C, Ronsmans C, Chandra PS, Sikander S, De Silva MJ, Patel V. Contribution of suicide and injuries to pregnancy-related mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Psychiatry 2014; 1:213-25. [PMID: 26360733 PMCID: PMC4567698 DOI: 10.1016/s2215-0366(14)70282-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although suicide is one of the leading causes of deaths in young women in low-income and middle-income countries, the contribution of suicide and injuries to pregnancy-related mortality remains unknown. METHODS We did a systematic review to identify studies reporting the proportion of pregnancy-related deaths attributable to suicide or injuries, or both, in low-income and middle-income countries. We used a random-effects meta-analysis to calculate the pooled prevalence of pregnancy-related deaths attributable to suicide, stratified by WHO region. To account for the possible misclassification of suicide deaths as injuries, we calculated the pooled prevalence of deaths attributable to injuries, and undertook a sensitivity analysis reclassifying the leading methods of suicides among women in low-income and middle-income countries (burns, poisoning, falling, or drowning) as suicide. FINDINGS We identified 36 studies from 21 countries. The pooled total prevalence across the regions was 1·00% for suicide (95% CI 0·54-1·57) and 5·06% for injuries (3·72-6·58). Reclassifying the leading suicide methods from injuries to suicide increased the pooled prevalence of pregnancy-related deaths attributed to suicide to 1·68% (1·09-2·37). Americas (3·03%, 1·20-5·49), the eastern Mediterranean region (3·55%, 0·37-9·37), and the southeast Asia region (2·19%, 1·04-3·68) had the highest prevalence for suicide, with the western Pacific (1·16%, 0·00-4·67) and Africa (0·65%, 0·45-0·88) regions having the lowest. INTERPRETATION The available data suggest a modest contribution of injuries and suicide to pregnancy-related mortality in low-income and middle-income countries with wide regional variations. However, this study might have underestimated suicide deaths because of the absence of recognition and inclusion of these causes in eligible studies. We recommend that injury-related and other co-incidental causes of death are included in the WHO definition of maternal mortality to promote measurement and effective intervention for reduction of maternal mortality in low-income and middle-income countries. FUNDING National Institute of Mental Health.
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Affiliation(s)
- Daniela C Fuhr
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Clara Calvert
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Carine Ronsmans
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Prabha S Chandra
- National Institute of Mental Health and Neurosciences, Bangalore
| | - Siham Sikander
- Human Development Research Foundation, Islamabad, Pakistan
| | - Mary J De Silva
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Vikram Patel
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK; Centre for Mental Health, Public Health Foundation of India, New Delhi, India; Sangath, Goa, India.
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Pirkle CM, Dumont A, Traoré M, Zunzunegui MV. Training and nutritional components of PMTCT programmes associated with improved intrapartum quality of care in Mali and Senegal. Int J Qual Health Care 2014; 26:174-83. [PMID: 24550261 DOI: 10.1093/intqhc/mzu013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Scale-up of prevention of mother-to-child transmission (PMTCT) of HIV programmes in sub-Saharan Africa has stimulated interest to assess whether these programmes can indirectly affect other health priorities. This study assesses whether PMTCT programmes, or components of these programmes, are associated with better obstetrical quality of care and how PMTCT may reinforce existing maternal health programmes. DESIGN Cross-sectional analysis of data from a cluster-randomized trial called QUARITE. SETTING Mali and Senegal, West Africa. PARTICIPANTS Thirty-one referral hospitals and 612 obstetrical patients. INTERVENTION The exposure of interest was PMTCT measured with a scale containing 10 components describing different prongs of a hospital PMTCT programme. Other variables of interest included: presence of a quality of care improvement programme, hospital resources and patient demographic characteristics. MAIN OUTCOME MEASURE Obstetrical quality of care measured through a validated chart abstraction tool. RESULTS Of 45 points, the mean hospital PMTCT score was 26.1 (SD: 6.7). Total PMTCT score was not significantly associated with quality of care, but programme component scores were. After adjustment for known predictors of quality of care, staff training in PMTCT (P = 0.03) and complementary nutritional services (P = 0.03) were significantly associated with better quality obstetrical care. A point increase in scores for either of these components was associated with 40% greater odds of good obstetrical care. CONCLUSIONS PMTCT training and nutritional components are significantly associated with better quality intrapartum care. Health professionals' training in maternal healthcare and PMTCT could be combined to improve the quality of obstetric care in the region.
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Affiliation(s)
- Catherine McLean Pirkle
- Axe Santé publique et pratiques optimales en santé, Centre de recherche du CHUQ, 2875, boulevard Laurier, Édifice Delta II, Bureau 600, 6e étage, Québec (Québec), Canada G1V 2M2.
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Effect of a facility-based multifaceted intervention on the quality of obstetrical care: a cluster randomized controlled trial in Mali and Senegal. BMC Pregnancy Childbirth 2013; 13:24. [PMID: 23351269 PMCID: PMC3599612 DOI: 10.1186/1471-2393-13-24] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 01/08/2013] [Indexed: 11/10/2022] Open
Abstract
Background Maternal mortality in referral hospitals in Mali and Senegal surpasses 1% of obstetrical admissions. Poor quality obstetrical care contributes to high maternal mortality; however, poor care is often linked to insufficient hospital resources. One promising method to improve obstetrical care is maternal death review. With a cluster randomized trial, we assessed whether an intervention, based on maternal death review, could improve obstetrical quality of care. Methods The trial began with a pre-intervention year (2007), followed by two years of intervention activities and a post-intervention year. We measured obstetrical quality of care in the post-intervention year using a criterion-based clinical audit (CBCA). We collected data from 32 of the 46 trial hospitals (16 in each trial arm) and included 658 patients admitted to the maternity unit with a trial of labour. The CBCA questionnaire measured 5 dimensions of care- patient history, clinical examination, laboratory examination, delivery care and postpartum monitoring. We used adjusted mixed models to evaluate differences in CBCA scores by trial arms and examined how levels of hospital human and material resources affect quality of care differences associated with the intervention. Results For all women, the mean percentage of care criteria met was 66.3 (SD 13.5). There were significantly greater mean CBCA scores in women treated at intervention hospitals (68.2) compared to control hospitals (64.5). After adjustment, women treated at intervention sites had 5 points’ greater scores than those at control sites. This difference was mostly attributable to greater clinical examination and post-partum monitoring scores. The association between the intervention and quality of care was the same, irrespective of the level of resources available to a hospital; however, as resources increased, so did quality of care scores in both arms of the trial. Trial registration The QUARITE trial is registered on the Current Controlled Trials website under
ISRCTN46950658
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Dumont A, Gueye M, Sow A, Diop I, Konate MK, Dambé P, Abrahamowicz M, Fournier P. [Using routine information system data to assess maternal and perinatal care services in Mali and Senegal (QUARITE trial)]. Rev Epidemiol Sante Publique 2012; 60:489-96. [PMID: 23121995 DOI: 10.1016/j.respe.2012.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 04/26/2012] [Accepted: 05/10/2012] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, problems of access to relevant and high-quality facility-based statistics hinder the assessment of safe motherhood programs. The objective of this study was to assess the quality of data collected in referral hospitals in Mali and Senegal after the routine information system (RIS) was strengthened. METHODS This was a multicenter observational study conducted during the pre-intervention period of a randomized controlled trial (trial QUARITE). The RIS was strengthened based on technical, organizational and behavioral factors. We included all women who gave birth in the 46 referral hospitals from October 1, 2007 to October 30, 2008. The completeness, completion and accuracy rates were monitored every 3 months in each hospital. The cost of investment needed to strengthen the existing RIS was also determined. RESULTS The mean completeness rate ranged from 94 to 97% depending on the study period. The completion and accuracy rates increased during the study period from 72% and 79% to 87% and 93%, respectively (significant differences). The average investment per hospital was less than 1% of state subsidies for public hospitals. CONCLUSION Strengthening the existing information system has set up an economically and technologically appropriate system for monitoring maternal and perinatal health in Senegal and Mali. We encourage policy makers and researchers from countries with limited resources to invest in RIS to improve and monitor the performance of health systems.
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Pirkle CM, Dumont A, Traore M, Zunzunegui MV. Validity and reliability of criterion based clinical audit to assess obstetrical quality of care in West Africa. BMC Pregnancy Childbirth 2012; 12:118. [PMID: 23106962 PMCID: PMC3514290 DOI: 10.1186/1471-2393-12-118] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 10/22/2012] [Indexed: 11/10/2022] Open
Abstract
Background In Mali and Senegal, over 1% of women die giving birth in hospital. At some hospitals, over a third of infants are stillborn. Many deaths are due to substandard medical practices. Criterion-based clinical audits (CBCA) are increasingly used to measure and improve obstetrical care in resource-limited settings, but their measurement properties have not been formally evaluated. In 2011, we published a systematic review of obstetrical CBCA highlighting insufficient considerations of validity and reliability. The objective of this study is to develop an obstetrical CBCA adapted to the West African context and assess its reliability and validity. This work was conducted as a sub-study within a cluster randomized trial known as QUARITE. Methods Criteria were selected based on extensive literature review and expert opinion. Early 2010, two auditors applied the CBCA to identical samples at 8 sites in Mali and Senegal (n = 185) to evaluate inter-rater reliability. In 2010–11, we conducted CBCA at 32 hospitals to assess construct validity (n = 633 patients). We correlated hospital characteristics (resource availability, facility perinatal and maternal mortality) with mean hospital CBCA scores. We used generalized estimating equations to assess whether patient CBCA scores were associated with perinatal mortality. Results Results demonstrate substantial (ICC = 0.67, 95% CI 0.54; 0.76) to elevated inter-rater reliability (ICC = 0.84, 95% CI 0.77; 0.89) in Senegal and Mali, respectively. Resource availability positively correlated with mean hospital CBCA scores and maternal and perinatal mortality were inversely correlated with hospital CBCA scores. Poor CBCA scores, adjusted for hospital and patient characteristics, were significantly associated with perinatal mortality (OR 1.84, 95% CI 1.01-3.34). Conclusion Our CBCA has substantial inter-rater reliability and there is compelling evidence of its validity as the tool performs according to theory. Trial registration Current Controlled Trials ISRCTN46950658
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Affiliation(s)
- Catherine M Pirkle
- Department of Social and Preventive Medicine, Université de Montréal, Montréal, Canada.
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Abstract
Increasing contraceptive use in developing countries has cut the number of maternal deaths by 40% over the past 20 years, merely by reducing the number of unintended pregnancies. By preventing high-risk pregnancies, especially in women of high parities, and those that would have ended in unsafe abortion, increased contraceptive use has reduced the maternal mortality ratio--the risk of maternal death per 100,000 livebirths--by about 26% in little more than a decade. A further 30% of maternal deaths could be avoided by fulfilment of unmet need for contraception. The benefits of modern contraceptives to women's health, including non-contraceptive benefits of specific methods, outweigh the risks. Contraception can also improve perinatal outcomes and child survival, mainly by lengthening interpregnancy intervals. In developing countries, the risk of prematurity and low birthweight doubles when conception occurs within 6 months of a previous birth, and children born within 2 years of an elder sibling are 60% more likely to die in infancy than are those born more than 2 years after their sibling.
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Affiliation(s)
- John Cleland
- London School of Hygiene and Tropical Medicine, London, UK.
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Pirkle CM, Fournier P, Tourigny C, Sangaré K, Haddad S. Emergency obstetrical complications in a rural African setting (Kayes, Mali): the link between travel time and in-hospital maternal mortality. Matern Child Health J 2012; 15:1081-7. [PMID: 20697934 DOI: 10.1007/s10995-010-0655-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The West African country of Mali implemented referral systems to increase spatial access to emergency obstetrical care and lower maternal mortality. We test the hypothesis that spatial access- proxied by travel time during the rainy and dry seasons- is associated with in-hospital maternal mortality. Effect modification by caesarean section is explored. All women treated for emergency obstetrical complications at the referral hospital in Kayes, Mali were considered eligible for study. First, we conducted descriptive analyses of all emergency obstetrical complications treated at the referral hospital between 2005 and 2007. We calculated case fatality rates by obstetric diagnosis and travel time. Key informant interviews provided travel times. Medical registers provided clinical and demographic data. Second, a matched case-control study assessed the independent effect of travel time on maternal mortality. Stratification was used to explore effect modification by caesarean section. Case fatality rates increased with increasing travel time to the hospital. After controlling for age, diagnosis, and date of arrival, a travel time of four or more hours was significantly associated with in-hospital maternal mortality (OR: 3.83; CI: 1.31-11.27). Travel times between 2 and 4 h were associated with increased odds of maternal mortality (OR 1.88), but the relationship was not significant. The effect of travel time on maternal mortality appears to be modified by caesarean section. Poor spatial access contributes to maternal mortality even in women who reach a health facility. Improving spatial access will help women arrive at the hospital in time to be treated effectively.
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Affiliation(s)
- Catherine McLean Pirkle
- Unité de Santé Internationale, Centre de recherche du Centre hospitalier de l'Université de Montréal, Édifice Saint-Urbain 3875 rue Saint-Urbain 5ième étage, Montreal, QC, H2W 1V1, Canada.
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Amarin Z, Khader Y, Okour A, Jaddou H, Al-Qutob R. National maternal mortality ratio for Jordan, 2007-2008. Int J Gynaecol Obstet 2011; 111:152-6. [PMID: 20810108 DOI: 10.1016/j.ijgo.2010.05.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 05/26/2010] [Accepted: 06/16/2010] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To estimate the number of maternal deaths per 100000 live births during 2007-2008 among Jordanian women; to identify the causes of maternal mortality; and to compare the results with those of the last report for 1995-1996. METHODS Reproductive-age mortality study of maternal deaths among women aged 15-49 years in Jordan in 2007-2008. RESULTS Among 1406 identified deaths of reproductive-aged women, 76 maternal deaths were identified out of 397588 live births, for a maternal mortality ratio of 19.1 deaths per 100000 live births. Forty-three (56.6%) deaths were attributable to hemorrhage, thrombosis and thromboembolism, and sepsis. Avoidable factors were present in 53.9% of women, 52.6% had substandard care, and 31.5% had 3 or fewer antenatal visits. Of those with available information on family planning, only 29.4% had ever used any form of contraception. CONCLUSIONS Maternal deaths in Jordan are declining. The maternal mortality ratio of 19.1 deaths per 100000 live births reported for 2007-2008 showed a remarkable reduction of 53.9% achieved in the 12 years since the 1995-1996 report (a 4.5% annual reduction), which is approaching the 75% reduction recommended by Millennium Development Goal 5.
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Affiliation(s)
- Zouhair Amarin
- Jordan University of Science and Technology, Irbid, Jordan.
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Morestin F, Bicaba A, Sermé JDD, Fournier P. Evaluating quality of obstetric care in low-resource settings: building on the literature to design tailor-made evaluation instruments--an illustration in Burkina Faso. BMC Health Serv Res 2010; 10:20. [PMID: 20089170 PMCID: PMC2837005 DOI: 10.1186/1472-6963-10-20] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 01/20/2010] [Indexed: 11/13/2022] Open
Abstract
Background There are many instruments available freely for evaluating obstetric care quality in low-resource settings. However, this profusion can be confusing; moreover, evaluation instruments need to be adapted to local issues. In this article, we present tools we developed to guide the choice of instruments and describe how we used them in Burkina Faso to facilitate the participative development of a locally adapted instrument. Methods Based on a literature review, we developed two tools: a conceptual framework and an analysis grid of existing evaluation instruments. Subsequently, we facilitated several sessions with evaluation stakeholders in Burkina Faso. They used the tools to develop a locally adapted evaluation instrument that was subsequently tested in six healthcare facilities. Results Three outputs emerged from this process: 1) A comprehensive conceptual framework for the quality of obstetric care, each component of which is a potential criterion for evaluation. 2) A grid analyzing 37 instruments for evaluating the quality of obstetric care in low-resource settings. We highlight their key characteristics and describe how the grid can be used to prepare a new evaluation. 3) An evaluation instrument adapted to Burkina Faso. We describe the experience of the Burkinabé stakeholders in developing this instrument using the conceptual framework and the analysis grid, while taking into account local realities. Conclusions This experience demonstrates how drawing upon existing instruments can inspire and rationalize the process of developing a new, tailor-made instrument. Two tools that came out of this experience can be useful to other teams: a conceptual framework for the quality of obstetric care and an analysis grid of existing evaluation instruments. These provide an easily accessible synthesis of the literature and are useful in integrating it with the context-specific knowledge of local actors, resulting in evaluation instruments that have both scientific and local legitimacy.
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Affiliation(s)
- Florence Morestin
- International Health Unit, CRCHUM (Research Centre of the University of Montreal Hospital Centre)/University of Montreal, Montreal, Quebec, Canada.
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Dumont A, Tourigny C, Fournier P. Improving obstetric care in low-resource settings: implementation of facility-based maternal death reviews in five pilot hospitals in Senegal. HUMAN RESOURCES FOR HEALTH 2009; 7:61. [PMID: 19627605 PMCID: PMC2728704 DOI: 10.1186/1478-4491-7-61] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 07/23/2009] [Indexed: 05/28/2023]
Abstract
BACKGROUND In sub-Saharan Africa, maternal and perinatal mortality and morbidity are major problems. Service availability and quality of care in health facilities are heterogeneous and most often inadequate. In resource-poor settings, the facility-based maternal death review or audit is one of the most promising strategies to improve health service performance. We aim to explore and describe health workers' perceptions of facility-based maternal death reviews and to identify barriers to and facilitators of the implementation of this approach in pilot health facilities of Senegal. METHODS This study was conducted in five reference hospitals in Senegal with different characteristics. Data were collected from focus group discussions, participant observations of audit meetings, audit documents and interviews with the staff of the maternity unit. Data were analysed by means of both quantitative and qualitative approaches. RESULTS Health professionals and service administrators were receptive and adhered relatively well to the process and the results of the audits, although some considered the situation destabilizing or even threatening. The main barriers to the implementation of maternal deaths reviews were: (1) bad quality of information in medical files; (2) non-participation of the head of department in the audit meetings; (3) lack of feedback to the staff who did not attend the audit meetings. The main facilitators were: (1) high level of professional qualifications or experience of the data collector; (2) involvement of the head of the maternity unit, acting as a moderator during the audit meetings; (3) participation of managers in the audit session to plan appropriate and realistic actions to prevent other maternal deaths. CONCLUSION The identification of the barriers to and the facilitators of the implementation of maternal death reviews is an essential step for the future adaptation of this method in countries with few resources. We recommend for future implementation of this method a prior enhancement of the perinatal information system and initial training of the members of the audit committee--particularly the data collector and the head of the maternity unit. Local leadership is essential to promote, initiate and monitor the audit process in the health facilities.
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Affiliation(s)
- Alexandre Dumont
- UR10 « santé de la mère et de l'enfant en milieu tropical », Institut de Recherche pour le Développement, Dakar, Sénégal
| | - Caroline Tourigny
- Unité de Santé Internationale, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Canada
| | - Pierre Fournier
- Unité de Santé Internationale, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Canada
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Cabero Roura L, Keith LG. Post-partum haemorrhage: Diagnosis, prevention and management. J Matern Fetal Neonatal Med 2009; 22 Suppl 2:38-45. [DOI: 10.1080/14767050902860609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Seale AC, Mwaniki M, Newton CRJC, Berkley JA. Maternal and early onset neonatal bacterial sepsis: burden and strategies for prevention in sub-Saharan Africa. THE LANCET. INFECTIOUS DISEASES 2009; 9:428-38. [PMID: 19555902 PMCID: PMC2856817 DOI: 10.1016/s1473-3099(09)70172-0] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Maternal and child health are high priorities for international development. Through a Review of published work, we show substantial gaps in current knowledge on incidence (cases per live births), aetiology, and risk factors for both maternal and early onset neonatal bacterial sepsis in sub-Saharan Africa. Although existing published data suggest that sepsis causes about 10% of all maternal deaths and 26% of neonatal deaths, these are likely to be considerable underestimates because of methodological limitations. Successful intervention strategies in resource-rich settings and early studies in sub-Saharan Africa suggest that the burden of maternal and early onset neonatal bacterial sepsis could be reduced through simple interventions, including antiseptic and antibiotic treatment. An effective way to expedite evidence to guide interventions and determine the incidence, aetiology, and risk factors for sepsis in sub-Saharan Africa would be through a multiarmed factorial intervention trial aimed at reducing both maternal and early onset neonatal bacterial sepsis in sub-Saharan Africa.
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MESH Headings
- Adolescent
- Adult
- Africa South of the Sahara/epidemiology
- Female
- Humans
- Incidence
- Infant, Newborn
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/mortality
- Infant, Newborn, Diseases/prevention & control
- Pregnancy
- Pregnancy Complications, Infectious/epidemiology
- Pregnancy Complications, Infectious/mortality
- Pregnancy Complications, Infectious/prevention & control
- Risk Factors
- Sepsis/epidemiology
- Sepsis/mortality
- Sepsis/prevention & control
- Young Adult
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Affiliation(s)
- Anna C Seale
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute, Kilifi, Kenya.
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Zakariah AY, Alexander S, van Roosmalen J, Buekens P, Kwawukume EY, Frimpong P. Reproductive age mortality survey (RAMOS) in Accra, Ghana. Reprod Health 2009; 6:7. [PMID: 19497092 PMCID: PMC2694771 DOI: 10.1186/1742-4755-6-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Accepted: 06/04/2009] [Indexed: 11/10/2022] Open
Abstract
Background Maternal mortality remains a severe problem in many parts of the world, despite efforts to reach MDG 5. In addition, underreporting is an issue especially in low income countries. Our objective has been to identify the magnitude of maternal deaths and the degree of underreporting of these deaths in Accra Metropolis in Ghana during a one year period. Methods A Reproductive Age Mortality survey (RAMOS) was carried out in the Accra Metropolis for the period 1st January 2002-31st December 2002. We reviewed records of female deaths aged 10–50 years in the Metropolis for the whole year 2002 using multiple sources. Maternal deaths identified through the review were compared with the officially reported maternal deaths for the same period. Results At the end of the study, a total of 179 maternal deaths out of 9,248 female deaths between the ages of 10–50 years were identified. One hundred and one (N = 101) of these were reported, giving an underreporting rate of 44%. The 179 cases consisted of 146 (81.6%) direct maternal deaths and 32 (17.9%) indirect maternal deaths and 1 (0.6%) non maternal death. The most frequent causes of direct maternal deaths were obstetric haemorrhage (57; 32%), pregnancies with abortive outcome (37; 20.8%), (pre) eclampsia (26; 14.6%) and puerperal sepsis (13; 7.3%). The most frequent indirect cause was sickle cell crisis in pregnancy (13; 7.3%). Conclusion A Reproductive Age Mortality Survey is an effective method that could be used to update data on maternal mortality in Ghana while efforts are made to improve on maternal death audits in the health facilities. Strengthening the existing community based volunteers to report deaths that take place at home and the civil registration systems of births and deaths is also highly recommended.
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Confidential inquiries into maternal deaths: Modifications and adaptations in Ghana and Indonesia. Int J Gynaecol Obstet 2009; 106:80-4. [DOI: 10.1016/j.ijgo.2009.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Affiliation(s)
- José M Carrera
- MATRES MUNDI, Trav. de Gracia 84, Bajos, 08006 Barcelona, Spain.
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25
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26
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Abstract
BACKGROUND One of the United Nations' Millennium Development Goals for 2015 is to reduce the maternal mortality ratio by three fourths. Ninety-nine percent of maternal deaths occur in developing countries, and the World Health Organization encourages investigations in these settings to determine the risk factors of maternal deaths. Our aim was to identify these risk factors in a hospital-based study in Mexico. METHODS The study was conducted at the Hospital of Obstetrics and Gynecology at the Mexican Institute of Social Security in Leon, Guanajuato, Mexico, from January 1, 1992, to March 31, 2004. Women were divided into groups of 110 individuals who had died during pregnancy, delivery, or postpartum, and 440 women who survived the postpartum period. We used a logistic regression analysis to find the significant risk factors for maternal deaths. Odds ratios with 95% t confidence intervals were estimated. RESULTS The maternal mortality ratio was 47.3 per 100,000 live births. The main causes of death were hemorrhage (30.9%), preeclampsia/eclampsia (28.2%), and septic shock (10.9%). Six factors were significantly associated with maternal death: age (OR = 1.09, 95% CI = 1.00-1.18), marital status (OR = 16.2, 95% CI = 1.3-196.1), number of antenatal visits (OR = 1.3, 95% CI = 1.0-1.6), preexisting medical conditions (OR = 23.3, 95% CI = 6.6-81.6), obstetric complications in previous pregnancies (OR = 28.3, 95% CI = 4.9-163.0), and mode of delivery (OR = 1.6, 95% CI = 1.0-2.4). CONCLUSIONS Socioeconomic, medical, and obstetric risk factors are associated with maternal deaths in Mexico.
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Affiliation(s)
- Gustavo Romero-Gutiérrez
- Hospital of Obstetrics and Gynecology, Division of Health Research, Mexican Institute of Social Security, Leon, Guanajuato, Mexico
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Abstract
OBJECTIVE To identify the determinants of skilled and unskilled birth attendance. METHOD Population-based survey in a rural area in Cambodia, of women aged 15-49 years who had delivered during the previous 3-month period. An analytical framework based on Andersen's behavioural model served to identify determinants according to delivery place (facility vs. non-facility), birth attendant at home births (skilled vs. unskilled), and change of birth attendant during delivery (changed vs. unchanged). We used logistic regression to analyse the data. RESULTS Of 980 women included in the analyses, 19.8% had skilled attendants present during delivery. The determinants of facility delivery were different from those for having skilled attendants assisting in home births. In case of facility deliveries, previous contact with a skilled attendant through antenatal care was a significant determinant. In case of home births, the type of birth attendant (i.e. skilled or unskilled) at the preceding delivery was a significant determinant. CONCLUSION Community-based programmes need to reach primiparas, because once a woman has delivered with the aid of an unskilled attendant, she is five to seven times less likely to seek skilled help than a primipara.
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Affiliation(s)
- Satoko Yanagisawa
- School of Health Sciences, Faculty of Medicine, Shinshu University, Nagano, Japan.
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Dumont A, Gaye A, Mahé P, Bouvier-Colle MH. Emergency obstetric care in developing countries: impact of guidelines implementation in a community hospital in Senegal. BJOG 2005; 112:1264-9. [PMID: 16101606 DOI: 10.1111/j.1471-0528.2005.00604.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate, with volunteer professionals in a resource-poor setting, an approach of audit and feedback to promote local implementation of emergency obstetric guidelines. DESIGN Triple cohort observational time series study. SETTING A 46-bed obstetric unit in an academic-affiliated community hospital in Senegal. POPULATION All pregnant women with haemorrhagic and hypertensive complications who were admitted to the maternity unit during the study periods. METHODS To assess the benefits of guidelines implementation, maternal outcomes during the intervention period were compared with those occurring in two one-year periods when staff daily supervision was the main potentially effective action on clinical management. MAIN OUTCOME MEASURES The intervention strategy was criteria-based audits with regular feedback over a one-year period. The clinical focus was haemorrhage and hypertension the most frequent causes of maternal death in the study population. Hospital charts were audited by external reviewers. The primary outcome was the case fatality rate (CFR) among patients with haemorrhage and hypertension. RESULTS There was an increase in morbidity diagnoses during the intervention period. In addition, there was a marked increase in obstetric interventions, especially for transfusions and caesarean deliveries. Patients characteristic-adjusted case fatality decreased by 53% between baselines I and II and during the intervention period by 33% and 24%, compared with baseline periods I and II, respectively. Outcome improvements were different for haemorrhage and hypertension. CONCLUSION While staff daily supervision may have improved maternal outcome before the intervention period, audit and feedback produced marked effects on emergency obstetric care, specially for complications requiring highly trained management (e.g. pre-eclampsia). Audit and feedback are one of the potentially effective guidelines implementation strategies that should be considered for further studies in resource-poor health facilities.
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Affiliation(s)
- Alexandre Dumont
- Department of Obstetrics and Gynaecology, Centre de Recherche de l'Hôpital Sainte-Justine, University of Montréal, Montréal, Quebec,Canada
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Abstract
OBJECTIVE This study was undertaken to identify the main causes of maternal mortality within a developed country to refocus and enhance the delivery of obstetric services. STUDY DESIGN From January 1, 1983, to December 31, 2000, 309 maternal deaths occurring in Bavaria were documented and classified in a prospective observational study. The data sources were the civil registry, confidential reports by members of the Bavarian Society of Obstetrics and Gynecology, and public information. Direct obstetric death, indirect obstetric death, and coincidental death account for 164, 67, and 78 cases, respectively. They were expressed as the maternal mortality ratio (MMR: maternal deaths/100,000 live births) over the 18-year study period divided into three 6-year intervals 1983 to 1988, 1989 to 1994, and 1995 to 2000. RESULTS The direct obstetric mortality ratio (DOMR: direct obstetric deaths/100,000 live births) decreased from 11.3 in the study period 1983 to 1988 to 5.4 in the study period 1995 to 2000 (P<.0005), mainly because of a reduction in antepartal and intrapartal deaths. The main cause of direct obstetric death was thromboembolism, including amniotic fluid embolism, which remained unchanged over the study period; other causes of direct obstetric death decreased markedly but not significantly. CONCLUSION Careful analysis of the Bavarian maternal mortality data identified postpartum maternal deaths to be unchanged during the study period. In particular, effective prevention and treatment of thromboembolism should be a prior focus for obstetric care.
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Affiliation(s)
- Hermann Welsch
- Maternal Mortality Commission, Bavarian Society of Obstetrics and Gynaecology, Zurich, Switzerland
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Abstract
Of all health statistics mentioned by the World Health Organization (WHO), maternal mortality is unique in showing the largest discrepancy between developed and developing countries. Approximately 90% of maternal deaths (more than 0.5 million each year) occur in developing countries. Over the last century, almost all countries have accepted antenatal care principles. However, insufficiency of resources and lack of women's compliance were the main handicaps in developing countries and compelled these countries to apply various standard programs. Unfortunately, these programs are not sufficiently effective in the prevention and treatment of maternal mortality. Fixing the number (quantity) of antenatal visits and the static approach affect the "quality" of antenatal care. Bleeding, chronic anemia, hypertensive disorders, obstructed labor, unsafe abortions and infections are the main factors leading to maternal mortality. The majority of these factors are preventable. It is important to suspect the presence of any of these factors and to intervene promptly both during antenatal care and immediately after delivery. The evidence-based approach is a way of reaching this solution. Antenatal care is a concept that extends from pre-pregnancy to postpartum, leading to effective emergency care for unpredictable and predictable complications during pregnancy and childbirth. Worldwide policies are not always applicable to each country, coercing national policies. There is still a need for prospective randomized trials to clarify this concept and the relevant policies.
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Affiliation(s)
- Murat Yayla
- Dicle University School of Medicine, Obstetrics and Gynecology Department, Diyarbakir, Turkey.
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Ronsmans C, Etard JF, Walraven G, Høj L, Dumont A, de Bernis L, Kodio B. Maternal mortality and access to obstetric services in West Africa. Trop Med Int Health 2003; 8:940-8. [PMID: 14516306 DOI: 10.1046/j.1365-3156.2003.01111.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Process evaluation has become the mainstay of safe motherhood evaluation in developing countries, yet the extent to which indicators measuring access to obstetric services at the population level reflect levels of maternal mortality is uncertain. In this study we examine the association between population indicators of access to obstetric care and levels of maternal mortality in urban and rural West Africa. METHODS In this ecological study we used data on maternal mortality and access to obstetric services from two population-based studies conducted in 16 sites in eight West African countries: the Maternal Mortality and Obstetric Care in West Africa (MAMOCWA) study in rural Sénégal, Guinea-Bissau and The Gambia and the Morbidité Maternelle en Afrique de l'Ouest (MOMA) study in urban Burkina Faso, Côte d'Ivoire, Mali, Mauritanie, Niger and Sénégal. RESULTS In rural areas, maternal mortality, excluding early pregnancy deaths, was 601 per 100,000 live births, compared with 241 per 100,000 for urban areas [RR = 2.49 (CI 1.77-3.59)]. In urban areas, the vast majority of births took place in a health facility (83%) or with a skilled provider (69%), while 80% of the rural women gave birth at home without any skilled care. There was a relatively close link between levels of maternal mortality and the percentage of births with a skilled attendant (r = -0.65), in hospital (r = -0.54) or with a Caesarean section (r = -0.59), with marked clustering in urban and rural areas. Within urban or rural areas, none of the process indicators were associated with maternal mortality. CONCLUSION Despite the limitations of this ecological study, there can be little doubt that the huge rural-urban differences in maternal mortality are due, at least in part, to differential access to high quality maternity care. Whether any of the indicators examined here will by themselves be good enough as a proxy for maternal mortality is doubtful however, as more than half of the variation in mortality remained unexplained by any one of them.
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Affiliation(s)
- C Ronsmans
- Maternal Health Programme, Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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Chalumeau M, Bouvier-Colle MH, Breart G. Can clinical risk factors for late stillbirth in West Africa be detected during antenatal care or only during labour? Int J Epidemiol 2002; 31:661-8. [PMID: 12055171 DOI: 10.1093/ije/31.3.661] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Recent studies have shown that the most important risk factors for perinatal mortality in developing countries are not detectable during antenatal care but can be observed only shortly before or during labour. Although 60% of perinatal deaths in these countries are stillbirths, few epidemiological studies focus on them. We tested the hypothesis that the risk factors for late stillbirth in West Africa are detectable principally shortly before or during labour. METHODS Data came from a prospective population-based study (the MOMA survey) that collected information about 20 326 pregnant women in seven areas, primarily urban, in West Africa. RESULTS There were 19 870 singleton births. The stillbirth rate was 25.9 per 1000 total births (95% CI: 23.7-28.1). In the crude analysis, after adjustment and consideration of prevalence, the principal risk factors for late stillbirth were: late antenatal or intrapartum vaginal bleeding, intrapartum hypertension, dystocia, and infection. Other risk factors were: maternal height (<150 cm), maternal age (>35 years), previous stillbirths, hypertension at the 8-month antenatal visit and number of antenatal visits (<2). CONCLUSIONS The principal risk factors for late stillbirth observed in our study could be detected only in the late antenatal and intrapartum period. These results highlight the potential benefits of partograph use. They need to be confirmed by studies incorporating continuous intrapartum fetal monitoring.
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Affiliation(s)
- Martin Chalumeau
- Institut National de la Santé et de la Recherche Médicale. Unité 149 Recherches Epidémiologiques en Santé Périnatale et Santé des Femmes, Paris, France
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Abstract
Uterine rupture is an uncommon obstetric event. It is important because it continues to be associated with maternal mortality, especially in developing countries, and with major maternal morbidity, particularly peripartum hysterectomy. It is also associated with a high incidence of perinatal mortality and morbidity worldwide. This chapter examines the incidence, aetiology, clinical presentation, complications and prevention of uterine rupture. The key factor in the cause of rupture is whether or not the uterus is scarred. Rupture of an unscarred uterus is rare, usually traumatic, and its incidence decreases with improvement in obstetric practice. Rupture of the scarred uterus is more common, and usually occurs after a trial of labour in a patient with a previous Caesarean section. This chapter also explores how the incidence and complications of uterine rupture may be minimized, and yet the incidence of vaginal birth after Caesarean section (VBAC) optimized, in clinical practice.
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Geelhoed D, Visser L, Agordzo P, Asare K, van Leeuwen JS, van Roosmalen J. Active versus expectant management of the third stage of labor in rural Ghana. Acta Obstet Gynecol Scand 2002; 81:172-3. [PMID: 11942910 DOI: 10.1034/j.1600-0412.2002.810215.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Dumont A, de Bernis L, Bouvier-Colle MH, Bréart G. Caesarean section rate for maternal indication in sub-Saharan Africa: a systematic review. Lancet 2001; 358:1328-33. [PMID: 11684214 DOI: 10.1016/s0140-6736(01)06414-5] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Rates of caesarean sections in more-developed countries have been rising since 1970, and vary greatly between less-developed countries. Present estimates, based on data from more-developed countries need to be validated with data from less-developed countries. We estimated the need for caesarean section for maternal indication in a population of pregnant women in west Africa (MOMA survey). METHODS The expected caesarean section rate was calculated from the rate of obstetric risk in the MOMA population, and rates of caesarean section in published work. FINDINGS Three-quarters of women from hospitals of sub-Saharan Africa were delivered by caesarean section for maternal reasons. Such intervention was needed for six main reasons, protracted labour, abruptio placentae, previous caesarean section, eclampsia, placenta praevia, and malpresentation. Although the observed rate of caesarean section in west African women is 1.3%, our results, combined with those of published work suggest a range of 3.6-6.5% (median, 5.4%). INTERPRETATION Our method might not be strictly accurate, but it is simple and provides informative findings that can help policy makers and health planners in sub-Saharan Africa to design and follow up programmes to reach the optimum caesarean section rate. Moreover, application of this method to hospital data could improve practitioners' assessments in these countries.
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Affiliation(s)
- A Dumont
- Epidemiological Research Unit on Women and Children's Health, National Institute of Health and Medical Research (INSERM), Paris, France.
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