Are populations of postpartum women differentially served by community health worker programs: an observational cohort study from Zanzibar, Tanzania

BACKGROUND

Although community health worker (CHW) programs focus on improving access to healthcare, some individuals may not receive the intended quality or quantity of an intervention. The objective of this research was to examine if certain populations of pregnant women differentially experience the implementation of a community health worker-led maternal health intervention in Zanzibar.

METHODS

We included pregnant women enrolled in the Safer Deliveries (Uzazi Salama) program, which operated in 10 of 11 districts in Zanzibar, Tanzania between January 1, 2017, and June 19, 2019 (N = 33,914). The outcomes of interest were receipt of the entire postpartum intervention (three CHW visits) and time to first postpartum CHW visit (days). Visits by CHWs were done at the women's home, however, a telehealth option existed for women who were unable to be reached in-person. We conducted statistical tests to investigate the bivariate associations between our outcomes and each demographic and health characteristic. We used multivariate logistic regression to estimate the relationships between covariates and the outcomes and multivariate linear regression to estimate the association between covariates and the average time until first postpartum visit.

RESULTS

Higher parity (OR = 0.85; P = 0.014; 95%CI: 0.75-0.97), unknown or unreported HIV status (OR = 0.64; p < 0.001; 95%CI: 0.53-0.78), and receipt of phone consultations (OR = 0.77; p < 0.001; 95%CI: 0.69-0.87) were associated with a lower odds of receiving all postpartum visits. Similarly, women with an unknown or unreported HIV status (estimated mean difference of 1.81 days; p < 0.001; 95%CI: 1.03-2.59) and those who received a phone consultation (estimated mean difference of 0.83 days; p < 0.001; 95%CI: 0.43-1.23), on average, experienced delays to first visit. In addition, current delivery at a referral hospital was associated with lower odds of receiving a postpartum visit and longer time to first visit compared to delivery at home, cottage hospital, PHCU + , or district hospital. Women from all other districts received their first visit earlier than women from Kaskazini B. There were no differences in the odds of receiving the entire postpartum intervention by sociodemographic variables, including age, education, and poverty assessment indicators.

CONCLUSION

The results indicate no differences in intervention contact across wealth and education levels, suggesting that the program is effectively reaching women regardless of SES. However, women with other characteristics (e.g., higher parity, unknown or unreported HIV status) had lower odds of receiving the complete intervention. Overall, this work generates knowledge on existing disparities in intervention coverage and enables future programs to develop approaches to achieve equity in health care utilization and outcomes.

Audit identified modifiable factors in Hospital Care of Newborns in low-middle income countries: a scoping review

BACKGROUND

Audit of facility-based care provided to small and sick newborns is a quality improvement initiative that helps to identify the modifiable gaps in newborn care (BMC Pregnancy Childbirth 14: 280, 2014). The aim of this work was to identify literature on modifiable factors in the care of newborns in the newborn units in health facilities in low-middle-income countries (LMICs). We also set out to design a measure of the quality of the perinatal and newborn audit process.

METHODS

The scoping review was conducted using the methodology outlined by Arksey and O'Malley and refined by Levac et al, (Implement Sci 5:1-9, 2010). We reported our results using the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. We identified seven factors to ensure a successful audit process based on World Health Organisation (WHO) recommendations which we subsequently used to develop a quality of audit process score.

DATA SOURCES

We conducted a structured search using PubMed, CINAHL, EMBASE, LILACS, POPLINE and African Index Medicus.

STUDY SELECTION

Studies published in English between 1965 and December 2019 focusing on the identification of modifiable factors through clinical or mortality audits in newborn care in health facilities from LMICs.

DATA EXTRACTION

We extracted data on the study characteristics, modifiable factors and quality of audit process indicators.

RESULTS

A total of six articles met the inclusion criteria. Of these, four were mortality audit studies and two were clinical audit studies that we used to assess the quality of the audit process. None of the studies were well conducted, two were moderately well conducted, and four were poorly conducted. The modifiable factors were divided into three time periods along the continuum of newborn care. The period of newborn unit care had the highest number of modifiable factors, and in each period, the health worker related modifiable factors were the most dominant.

CONCLUSION

Based on the significant number of modifiable factors in the newborn unit, a neonatal audit tool is essential to act as a structured guide for auditing newborn unit care in LMICs. The quality of audit process guide is a useful method of ensuring high quality audits in health facilities.

Optimal Profile Limits for Maternal Mortality Rates (MMR) Influenced by Haemorrhage and Unsafe Abortion in South Sudan

Maternal mortality rate (MMR) is one of the main worldwide public health challenges. Presently, the high levels of MMR are a common problem in the world public health and especially, in developing countries. Half of these maternal deaths occur in Sub-Saharan Africa where little or nothing progress has been made. South Sudan is one of the developing countries which has the highest MMR. Thus, this paper deploys statistical analysis to identify the significant physiological causes of MMR in South Sudan. Prediction models based on Poisson Regression are then developed to predict MMR in terms of the significant physiological causes. Coefficients of determination and variance inflation factor are deployed to assess the influence of the individual causes on MMR. Efficacy of the models is assessed by analyzing their prediction errors. The paper for the first time has used optimization procedures to develop yearly lower and upper profile limits for MMR. Hemorrhaging and unsafe abortion are used to achieve UN 2030 lower and upper MMR targets. The statistical analysis indicates that reducing haemorrhaging by 1.91% per year would reduce MMR by 1.91% (95% CI (42.85–52.53)), reducing unsafe abortion by 0.49% per year would reduce MMR by 0.49% (95% CI (11.06–13.56)). The results indicate that the most influential predictors of MMR are; hemorrhaging (38%), sepsis (11.5%), obstructed labour (11.5%), unsafe abortion (10%), and indirect causes such as anaemia, malaria, and HIV/AIDs virus (29%). The results also show that to obtain the UN recommended MMR levels of minimum 21 and maximum 42 by 2030, the Government and other stakeholders should simultaneously, reduce haemorrhaging from the current value of 62 to 33.38 and 16.69, reduce unsafe abortion from the current value of 16 to 8.62 and 4.31. Thirty years of data is used to develop the optimal reduced Poisson Model based on hemorrhaging and unsafe abortion. The model with R² of 92.68% can predict MMR with mean error of −0.42329 and SE-mean of 0.02268. The yearly optimal level of hemorrhage, unsafe abortion, and MMR can aid the government and other stakeholders on resources allocation to reduce the risk of maternal death.

Maternal mortality due to cardiac disease in low- and middle-income countries

Objectives

To assess the frequency of maternal death (MD) due to cardiac disease in low‐ and middle‐income countries (LMIC).

Methods

Systematic review searching Medline, EMBASE, Web of Science, Cochrane Library, Emcare, LILACS, African Index Medicus, IMEMR, IndMED, WPRIM, IMSEAR up to 01/Nov/2017. Maternal mortality reports from LMIC reviewing all MD in a given geographical area were included. Hospital‐based reports or those solely based on verbal autopsies were excluded. Numbers of MD and cardiac‐related deaths were extracted. We calculated cardiac disease MMR (cMMR, cardiac‐related MD/100 000 live births) and proportion of cardiac‐related MDs among all MDs. Frequency of cardiac MD was compared with the MMR of the country.

Results

Forty‐seven reports were included, which reported on 38,486 maternal deaths in LMIC. Reported cMMR ranged from 0/100 000 live births (Moldova, Ghana) to 31.9/100 000 (Zimbabwe). The proportion of cardiac‐related MD ranged from 0% (Moldova, Ghana) to 24.8% (Sri Lanka). In countries with a higher MMR, cMMR was also higher. However, the proportion of cardiac‐related MD was higher in countries with a lower MMR.

Conclusions

The burden of cardiac‐related mortality is difficult to assess due limited availability of mortality reports. The proportion of cardiac deaths among all MD appeared to be higher in countries with a lower MMR. This is in line with what has been called ‘obstetric transition’: pre‐existing medical diseases including cardiac disease are becoming relatively more important where the MMR falls.

Shifting paradigm of maternal and perinatal death review system in Bangladesh: A real time approach to address sustainable developmental goal 3 by 2030

Recently, Bangladesh has made remarkable progress in reducing maternal and neonatal morality, even though the millennium developmental goal to reduce maternal and neonatal mortality was not achieved. Sustainable Developmental Goal (SDG) 3 has already been set for a new target to reduce maternal and neonatal deaths by 2030. The country takes this timely initiative to introduce a maternal and perinatal death review system. This review will discuss the shifting paradigm of the maternal and perinatal death review system in Bangladesh and its challenges in reaching the SDG on time. This review uses existing literature on the maternal and perinatal death review system in Bangladesh, and other systems in similar settings, as well as reports, case studies, news, government letters and meeting minutes.

Bangladesh introduced the maternal and perinatal death review system in 2010. Prior to this there was no such comprehensive death review system practiced in Bangladesh. The system was established within the government health system and has brought about positive effects and outcomes. Therefore, the Ministry of Health and Family Welfare of Bangladesh gradually scaled up the maternal and perinatal death review system nationwide in 2016 within the government health system. The present death review system highlighted real-time data use, using the district health information software(DHIS-2). Health mangers are able to take remedial action plans and implement strategies based on findings in DHIS-2. Therefore, effective utilization of data can play a pivotal role in the reduction of maternal and perinatal deaths in Bangladesh.

Overall, the maternal and perinatal death review system provides a great opportunity to achieve the SDG 3 on time. However, the system needs continuous monitoring at different levels to ensure its quality and validity of information, as well as effective utilization of findings for planning and implementation under a measureable accountability framework.

Factors Influencing Anti-Malarial Prophylaxis and Iron Supplementation Non-Compliance among Pregnant Women in Simiyu Region, Tanzania

Malaria and iron-deficient anemia during pregnancy pose considerable risks for the mother and newborn. Intermittent Preventive Treatment during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) and iron supplement to prevent anemia to all pregnant women receiving antenatal care (ANC) services is highly recommended. However, their compliance remains low. This study aimed at identifying factors influencing non-compliance of medications among pregnant women. A descriptive cross-sectional study was conducted in Simiyu region in northwest Tanzania using a structured questionnaire to collect data from 430 women who were pregnant or gave birth 12 months prior to data collection. Data were analyzed using non-parametric statistical analysis with STATA 10. Overall, 284 (66%) and 195 (45%) of interviewed women received IPTp-SP and iron supplementation during their ANC visits, respectively. The majority (85%) of women whom received medications were aware if they had received IPTp-SP or iron supplementation. Of those received IPTp-SP, only 11% took all the three doses, while the remaining 89% took only two doses or one dose. For women who received iron supplementation, 29% reported that they did not take any dose at all. Reasons given for not complying with regiments included not liking the medications and disapproval from male partners. Our findings suggest that IPTp-SP and iron supplement compliance among pregnant women in Simiyu region is low. Intensification of community education, further qualitative research and administration of medication through directly-observed therapy (DOT) are recommended to address the problem.

Uptake of intermittent preventive treatment with sulphadoxine-pyrimethamine for malaria during pregnancy and pregnancy outcomes: a cross-sectional study in Geita district, North-Western Tanzania

BACKGROUND

Malaria infection during pregnancy is associated with adverse outcomes in sub-Saharan Africa (SSA). For this reason, the World Health Organization currently recommends intermittent preventive treatment of malaria in pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) at each scheduled antenatal care (ANC) visit. In Tanzania, the revised IPTp policy was adopted in 2013 but the level of uptake and its association with pregnancy outcomes remains unknown.

METHODS

A cross-sectional study was conducted among singleton pregnant women who delivered in two selected health facilities of Geita district, northwestern Tanzania. Self-reported uptake of SP was verified using the ANC card and was recorded. Placental and peripheral blood was collected for diagnosis of malaria by microscopy and rapid diagnostic tests (RDTs). Gestational age was estimated based on last menstrual period or Ballard score. Infant birth weights were recorded within 24 hours of delivery.

RESULTS

Of 431 participants, 167 (38.75%), 134 (31.09%), 104 (24.23%), and 26 (6.03%) reported taking none, one, two, and ≥ three doses of SP during pregnancy, respectively. The uptake of ≥ three doses of IPTp-SP among delivering women at Geita hospital and Katoro health centre was 9.06% and 1.2%, respectively. The overall prevalence of malaria in pregnancy by RDT, peripheral and placental smears was 19.5%, 29.7% and 37.6% respectively. The prevalence of placental parasitaemia was higher for women who delivered at Katoro Health Centre (41.57%) than those who delivered at Geita hospital (35.09%). The uptake of ≥ three doses of SP was associated with reduced odds of having placental malaria (adjusted odds ratio (AOR) = 0.31, p = 0.039) compared to < three doses. Women with placental parasitaemia were five times more likely to have delivered pre-term (AOR = 4.67, p = 0.002) and had lower mean birth weight infants than their uninfected counterparts (mean difference = 82 g, p = 0.039).

CONCLUSIONS

The uptake of ≥ three doses of IPTp-SP is low in the present study area. Placental parasitaemia is prevalent and is associated with adverse birth outcomes. Receipt of ≥ three doses of IPTp-SP reduced the odds of placental parasitaemia. Thus, increased efforts towards scale-up and continuous evaluation of IPTp-SP efficacy is recommended.

Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review

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.

Acknowledging HIV and malaria as major causes of maternal mortality in Mozambique

OBJECTIVE

To review national data on HIV and malaria as causes of maternal death and to determine the importance of looking at maternal mortality at a subnational level in Mozambique.

METHODS

Three national data surveys were used to document HIV and malaria as causes of maternal mortality and to assess HIV and malaria prevention services for pregnant women. Data were collected between 2007 and 2011, and included population-level verbal autopsy data and household survey data.

RESULTS

Verbal autopsy data indicated that 18.2% of maternal deaths were due to HIV and 23.1% were due to malaria. Only 19.6% of recently pregnant women received at least two doses of sulfadoxine-pyrimethamine for intermittent preventive treatment, and only 42.3% of pregnant women were sleeping under an insecticide-treated net. Only 37.5% of recently pregnant women had been counseled, tested, and received an HIV test result. Coverage of prevention services varied substantially by province.

CONCLUSION

Triangulation of information on cause of death and coverage of interventions can enable appropriate targeting of maternal health interventions. Such information could also help countries in Sub-Saharan Africa to recognize and take action against malaria and HIV in an effort to decrease maternal mortality.

Psychosocial, behavioural and health system barriers to delivery and uptake of intermittent preventive treatment of malaria in pregnancy in Tanzania - viewpoints of service providers in Mkuranga and Mufindi districts

BACKGROUND

Intermittent preventive treatment of malaria in pregnancy (IPTp) using sulphurdoxine-pyrimethamine (SP) is one of key malaria control strategies in Africa. Yet, IPTp coverage rates across Africa are still low due to several demand and supply constraints. Many countries implement the IPTp-SP strategy at antenatal care (ANC) clinics. This paper reports from a study on the knowledge and experience of health workers (HWs) at ANC clinics regarding psychosocial, behavioural and health system barriers to IPTp-SP delivery and uptake in Tanzania.

METHODS

Data were collected through questionnaire-based interviews with 78 HWs at 28 ANC clinics supplemented with informal discussions with current and recent ANC users in Mkuranga and Mufindi districts. Qualitative data were analysed using a qualitative content analysis approach. Quantitative data derived from interviews with HWs were analysed using non-parametric statistical analysis.

RESULTS

The majority of interviewed HWs were aware of the IPTp-SP strategy's existence and of the recommended one month spacing of administration of SP doses. Some HWs were unsure of that it is not recommended to administer IPTp-SP and ferrous/folic acid concurrently. Others were administering three doses of SP per client following instruction from a non-governmental agency while believing that this was in conflict with national guidelines. About half of HWs did not find it appropriate for the government to recommend private ANC providers to provide IPTp-SP free of charge since doing so forces private providers to recover the costs elsewhere. HWs noted that pregnant women often register at clinics late and some do not comply with the regularity of appointments for revisits, hence miss IPTp and other ANC services. HWs also noted some amplified rumours among clients regarding health risks and treatment failures of SP used during pregnancy, and together with clients' disappointment with waiting times and the sharing of cups at ANC clinics for SP, limit the uptake of IPTp-doses.

CONCLUSION

HWs still question SP's treatment advantages and are confused about policy ambiguity on the recommended number of IPTp-SP doses and other IPTp-SP related guidelines. IPTp-SP uptake is further constrained by pregnant women's perceived health risks of taking SP and of poor service quality.

Availability and components of maternity services according to providers and users perspectives in North Gondar, Northwest Ethiopia

Background

The goal of reducing maternal mortality can be achieved when women receive important service components at the time of their maternity care. This study attempted to assess the availability and the components of maternity services according to the perspectives of service users and providers.

Method

A linked facility and population-based survey was conducted over three months (January to March 2012) in North Gondar Zone. Twelve kebeles (clusters) were selected randomly from six districts to identify maternity clients cared for by skilled providers. Then 12 health centers and 3 hospitals utilized by the corresponding cluster population were selected for facility survey. Interview with facility managers/heads, providers and clients and observations were used for data collection. Data were entered using Epi Info and were exported to SPSS software for analysis.

Results

Antenatal and delivery care were available in most of the visited facilities. However, the majority of them were not fully functioning for EmOC according to their level. Signal functions including administration of anticonvulsants and assisted vaginal delivery were missing in seven and five of the 12 health centers, respectively. Only one hospital met the criteria for comprehensive emergency obstetric care (performed cesarean section). Only 24% of the providers used partograph consistently. About 538 (32.3%) and 231 (13.8%) of the women received antenatal and delivery care from skilled providers, respectively. Most of the services were at health centers by nurses/midwives. At the time of the antenatal care, women received the important components of the services (percentage of users in bracket) like blood pressure checkup (79%), urine testing (35%), tetanus immunization (45%), iron supplementation (64%), birth preparedness counseling (51%) and HIV testing (71%). During delivery, 80% had their blood pressure measured, 78% were informed on labor progress, 89% had auscultation of fetal heartbeat, 80% took drugs to prevent bleeding and 78% had counseling on early & exclusive breast-feeding.

Conclusion

Antenatal and delivery care were available in most of the visited facilities. However, important components of both the routine and emergency maternity care services were incomplete. Improving the functional capacity of health facilities for the delivery of routine maternity and EmOC services are needed.

Applicability of the WHO maternal near miss criteria in a low-resource setting

Background

Maternal near misses are increasingly used to study quality of obstetric care. Inclusion criteria for the identification of near misses are diverse and studies not comparable. WHO developed universal near miss inclusion criteria in 2009 and these criteria have been validated in Brazil and Canada.

Objectives

To validate and refine the WHO near miss criteria in a low-resource setting.

Methods

A prospective cross-sectional study was performed in a rural referral hospital in Tanzania. From November 2009 until November 2011, all cases of maternal death (MD) and maternal near miss (MNM) were included. For identification of MNM, a local modification of the WHO near miss criteria was used, because most laboratory-based and some management-based criteria could not be applied in this setting. Disease-based criteria were added as they reflect severe maternal morbidity. In the absence of a gold standard for identification of MNM, the clinical WHO criteria were validated for identification of MD.

Results

32 MD and 216 MNM were identified using the locally adapted near miss criteria; case fatality rate (CFR) was 12.9%. WHO near miss criteria identified only 60 MNM (CFR 35.6%). All clinical criteria, 25% of the laboratory-based criteria and 50% of the management-based criteria could be applied. The threshold of five units of blood for identification of MNM led to underreporting of MNM. Clinical criteria showed specificity of 99.5% (95%CI: 99.4%–99.7%) and sensitivity of 100% (95%CI: 91.1%–100%). Some inclusion criteria did not contribute to the identification of cases and therefore may be eligible for removal.

Conclusion

The applicability of the WHO near miss criteria depends on the local context, e.g. level of health care. The clinical criteria showed good validity. Lowering the threshold for blood transfusion from five to two units in settings without blood bank and addition of disease-based criteria in low-resource settings is recommended.

Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis

BACKGROUND

The evaluation of all potential sources of low skilled maternal care utilization is crucial for Ethiopia. Previous studies have largely disregarded the contribution of different levels. This study was planned to assess the effect of individual, communal, and health facility characteristics in the utilization of antenatal, delivery, and postnatal care by a skilled provider.

METHODS

A linked facility and population-based survey was conducted over three months (January - March 2012) in twelve "kebeles" of North Gondar Zone, Amhara Region. A total of 1668 women who had births in the year preceding the survey were selected for analysis. Using a multilevel modelling, we examined the effect of cluster variation and a number of individual, communal (kebele), and facility-related variables for skilled maternal care utilization.

RESULT

About 32.3%, 13.8% and 6.3% of the women had the chance to get skilled providers for their antenatal, delivery and postnatal care, respectively. A significant heterogeneity was observed among clusters for each indicator of skilled maternal care utilization. At the individual level, variables related to awareness and perceptions were found to be much more relevant for skilled maternal service utilization. Preference for skilled providers and previous experience of antenatal care were consistently strong predictors of all indicators of skilled maternal health care utilizations. Birth order, maternal education, and awareness about health facilities to get skilled professionals were consistently strong predictors of skilled antenatal and delivery care use. Communal factors were relevant for both delivery and postnatal care, whereas the characteristics of a health facility were more relevant for use of skilled delivery care than other maternity services.

CONCLUSION

Factors operating at individual and "kebele" levels play a significant role in determining utilization of skilled maternal health services. Interventions to create better community awareness and perception about skilled providers and their care, and ensuring the seamless performance of health care facilities have been considered crucial to improve skilled maternal services in the study area. Such interventions should target underprivileged women.

The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania

Background

Intermittent preventive treatment during pregnancy (IPTp) at routine antenatal care (ANC) clinics is an important and efficacious intervention to reduce adverse health outcomes of malaria infections during pregnancy. However, coverage for the recommended two IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage.

Methods

Data on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Women's timing of ANC visits and health worker's timing of IPTp delivery were analyzed in relation to the different national IPTp schedules and the outcome on IPTp coverage was modelled.

Results

Among all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. Less than 1% of women started ANC attendance after 32 weeks of gestation. During the second IPTp delivery period health workers delivered IPTp to significantly less women than during the first one (55% vs. 73%) contributing to low second dose coverage. Simplified IPTp guidelines for front-line health workers as recommended by WHO could lead to a 20 percentage point increase in IPTp coverage.

Conclusions

This study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. To maximize the benefit of the IPTp intervention, revision of existing guidelines is needed. Training on simplified IPTp messages should be consolidated as part of the extended antenatal care training to change health workers' delivery practices and increase IPTp coverage. Pregnant women's knowledge about IPTp and the risks of malaria during pregnancy should be enhanced as well as their ability and power to demand IPTp and other ANC services.

Complications of childbirth and maternal deaths in Kinshasa hospitals: testimonies from women and their families

BACKGROUND

Maternal mortality in Kinshasa is high despite near universal availability of antenatal care and hospital delivery. Possible explanations are poor-quality care and by delays in the uptake of care. There is, however, little information on the circumstances surrounding maternal deaths. This study describes and compares the circumstances of survivors and non survivors of severe obstetric complications.

METHOD

Semi structured interviews with 208 women who survived their obstetric complication and with the families of 110 women who died were conducted at home by three experienced nurses under the supervision of EK. All the cases were identified from twelve referral hospitals in Kinshasa after admission for a serious acute obstetric complication. Transcriptions of interviews were analysed with N-Vivo 2.0 and some categories were exported to SPSS 14.0 for further quantitative analysis.

RESULTS

Testimonies showed that despite attendance at antenatal care, some women were not aware of or minimized danger signs and did not seek appropriate care. Cost was a problem; 5 deceased and 4 surviving women tried to avoid an expensive caesarean section by delivering in a health centre, although they knew the risk. The majority of surviving mothers (for whom the length of stay was known) had the caesarean section on the day of admission while only about a third of those who died did so. Ten women died before the required caesarean section or blood transfusion could take place because they did not bring the money in time. Negligence and lack of staff competence contributed to the poor quality of care. Interviews revealed that patients and their families were aware of the problem, but often powerless to do anything about it.

CONCLUSION

Our findings suggest that women with serious obstetric complications have a greater chance of survival in Kinshasa if they have cash, go directly to a functioning referral hospital and have some leverage when dealing with health care staff.

Malaria during pregnancy in endemic areas: a lens for examining maternal-fetal conflict

Most of our knowledge about maternal-fetal conflict derives from the battle over scarce nutritional resources. How do other stressors like infectious diseases alter the maternal-fetal relationship? In this article, we use the example of malaria infection during pregnancy to explore the altered maternal-fetal relationship in the presence of an infectious disease. While adults living in regions endemic to Plasmodium falciparum malaria are generally immune, pregnant women experience significantly more frequent and severe infections. These infections generally resolve within a few days of birth and rarely cross the placenta, but the infants often experience poor birth outcomes, particularly low birth weight. This article summarizes what is known about the proximate, or physiological, mechanisms by which malaria causes more severe or frequent infections for pregnant versus nonpregnant women in endemic regions and then utilizes an evolutionary approach to focus on the altered maternal-fetal relationship during malaria-infected pregnancy.

The epidemiology of pregnancy outcomes in rural Burkina Faso

OBJECTIVES

To describe levels and causes of pregnancy-related mortality and selected outcomes after pregnancy (OAP) in two districts of Burkina Faso.

METHODS

A household census was conducted in the two study districts, recording household deaths to women aged 12-49 years from 2001 to 2006. Questions on pregnancy outcomes in the last 5 years for resident women of reproductive age were included, and an additional method - direct sisterhood - was added in part of the area. Adult female deaths were followed-up with verbal autopsies (VA) with household members. A probabilistic model for interpreting VA data (InterVA-M) was used to determine distributions of probable causes of death. An OAP survey was conducted among all women with an experience of pregnancy during the prior 12 months. It aimed to document physical and psychological disabilities, economic and social consequences and discomfort that women may suffer as a result of a pregnancy.

RESULTS

The maternal mortality ratio (MMR) was 441 per 100 000 live births (95% CI: 397, 485), significantly higher in Diapaga [519 per 100 000 (95% CI: 454, 584)] than Ouargaye [353 per 100 000 (95% CI: 295, 411)]. MMRs were associated with wealth quintile, age and distance from a health facility. The causes of death showed higher than expected rates of sepsis (30%) and lower rates of haemorrhage (7%). A substantial proportion of all women had difficulty performing day-to-day tasks as a consequence of pregnancy. Women who had experienced stillbirths or Caesarean sections reported symptom-related indicators of poor physical health more frequently than women reporting uncomplicated deliveries, and were also more likely to be depressed.

CONCLUSIONS

Expectations on the levels and causes of pregnancy-related mortality in Burkina Faso may need to be re-examined, and this could have programmatic implications; for example high levels of sepsis could prompt renewed efforts to reach women with skilled attendance at delivery and follow-up during the postpartum period. Further documentation of how complication-induced disabilities affect women and their families is needed. For mortality and morbidity outcomes, demonstrating variation between study districts is important to empower local decision makers with evidence of need at a subnational level.

Risk factors for maternal death in the highlands of rural northern Tanzania: a case-control study

Background

Tanzania has one of the highest maternal mortality ratios in sub-Saharan Africa. Due to the paucity of epidemiological information on maternal deaths, and the high maternal mortality estimates found earlier in the study area, our objective was to assess determinants of maternal deaths in a rural setting in the highlands of northern Tanzania by comparing the women dying of maternal causes with women from the same population who had attended antenatal clinics in the same time period.

Methods

A case-control study was done in two administrative divisions in Mbulu and Hanang districts in rural Tanzania. Forty-five cases of maternal death were found through a comprehensive community- and health-facility based study in 1995 and 1996, while 135 antenatal attendees from four antenatal clinics in the same population, geographical area, and time-span of 1995–96 served as controls. The cases and controls were compared using multivariate logistic regression analyses. Odds ratios, with 95% confidence intervals, were used as an approximation of relative risk, and were adjusted for place of residence (ward) and age. Further adjustment was done for potentially confounding variables.

Results

An increased risk of maternal deaths was found for women from 35–49 years versus 15–24 years (OR 4.0; 95%CI 1.5–10.6). Women from ethnic groups other than the two indigenous groups of the area had an increased risk of maternal death (OR 13.6; 95%CI 2.5–75.0). There was an increased risk when women or husbands adhered to traditional beliefs, (OR 2.1; 95%CI 1.0–4.5) and (OR 2.6; 95%CI 1.2–5.7), respectively. Women whose husbands did not have any formal education appeared to have an increased risk (OR 2.2; 95%CI 1.0–5.0).

Conclusion

Increasing maternal age, ethnic and religious affiliation, and low formal education of the husbands were associated with increased risk of maternal death. Increased attention needs to be given to formal education of both men and women. In addition, education of the male decision-makers should be given high priority in the community, especially in matters concerning pregnancy and delivery preparedness, since their choice greatly affects the survival of the pregnant and delivering women.

Avoidable maternal mortality in Enugu, Nigeria

OBJECTIVE

The aim of this study was to identify avoidable factors in maternal mortality in Enugu, Nigeria.

STUDY DESIGN

A hospital-based descriptive study.

METHODS

The case records of maternal deaths in the Obstetric Unit of the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria, between January 2003 and December 2005, were studied to identify maternal characteristics and avoidable factors for maternal mortality. Booked women were those who received formal prenatal care in a medical facility. Abortion-related deaths were not included in the study.

RESULTS

There were 49 maternal deaths, 2131 deliveries and 2044 live births during the study period, giving a maternal mortality ratio of 2397.3 maternal deaths per 100,000 live births. The average age of the women was 29.8 years. Twelve women (25.5%) booked in the UNTH, 23 (48.9%) booked elsewhere and 12 (25.5%) were unbooked. Ten women (21.3%) were nulliparous, 15 (31.9%) were Para 1-2, 17 (36.2%) were Para 3-4 and five (10.6%) were Para 5 or above. Twenty-one women (44.7%) first sought medical attention at a private medical clinic, six (12.8%) at the general/mission hospital, five (10.6%) at maternity/health centres, one (2.1%) from a traditional birth attendant and 14 (29.8%) at the UNTH. Fourteen women (39.8%) died within 24h of admission, 12 (25.5%) between 24 and 48h, seven (14.9%) between 48 and 96h and 14 (29.8%) after 96h. Two women (4.3%) delivered at home, eight (17.0%) in private medical clinics, 23 (48.9%) in the UNTH and 14 (29.8%) died undelivered. Major avoidable factors were substandard care (27.7%), delay in seeking care (19.1%), financial constraints (8.4%), delay in recognizing a problem (6.4%), lack of blood (4.3%), lack of drugs (2.1%) and industrial strike action by health workers (2.1%). No major avoidable factor was identified in 14 women (29.8%).

CONCLUSION

Avoidable factors are still prevalent in maternal deaths in Nigeria.

Intermittent preventive treatment of malaria during pregnancy: a qualitative study of knowledge, attitudes and practices of district health managers, antenatal care staff and pregnant women in Korogwe District, North-Eastern Tanzania

BACKGROUND

Intermittent preventive treatment of malaria during pregnancy (IPTp) is a key intervention in the national strategy for malaria control in Tanzania. SP, the current drug of choice, is recommended to be administered in the second and third trimesters of pregnancy during antenatal care (ANC) visits. To allow for a proper design of planned scaling up of IPT services in Tanzania it is useful to understand the IPTp strategy's acceptability to health managers, ANC service providers and pregnant women. This study assesses the knowledge, attitudes and practices of these groups in relation to malaria control with emphasis on IPTp services.

METHODS

The study was conducted in February 2004, in Korogwe District, Tanzania. It involved in-depth interviews with the district medical officer (DMO), district hospital medical officer in charge and relevant health service staff at two peripheral dispensaries, and separate focus group discussions (FGDs) with district Council Health Management Team members at district level and pregnant women at dispensary and community levels.

RESULTS

Knowledge of malaria risks during pregnancy was high among pregnant women although some women did not associate coma and convulsions with malaria. Contacting traditional healers and self-medication with local herbs for malaria management was reported to be common. Pregnant women and ANC staff were generally aware of SP as the drug recommended for IPTp, albeit some nurses and the majority of pregnant women expressed concern about the use of SP during pregnancy. Some pregnant women testified that sometimes ANC staff allow the women to swallow SP tablets at home which gives a room for some women to throw away SP tablets after leaving the clinic. The DMO was sceptical about health workers' compliance with the direct observed therapy in administering SP for IPTp due to a shortage of clean water and cups at ANC clinics. Intensified sensitization of pregnant women about the benefits of IPTp was suggested by the study participants as an important approach for improving IPTp compliance.

CONCLUSION

The successful implementation of the IPTp strategy in Tanzania depends on the proper planning of, and support to, the training of health staff and sustained sensitization of pregnant women at health facility and community levels about the benefits of IPTp for the women and their unborn babies.

Artemether in the treatment of falciparum malaria during pregnancy in eastern Sudan

This study was carried in New Halfa Hospital, eastern Sudan from October 1997 to February 2001. Twenty-eight pregnant Sudanese women infected with Plasmodium falciparum were treated with intramuscular artemether (six injections, 480 mg) after failure of chloroquine and quinine therapy. The patients were followed-up until delivery; the babies were followed-up until the age of 1 year. Artemether was given to one patient in the tenth week of gestation, to 12 during the second trimester, and to 15 during the third trimester. It was well tolerated, the parasitaemia was cleared and the patients were symptom-free within three days. One patient (3.5%) delivered at 32 weeks and the baby died six hours after delivery. The other 27 (96.5%) delivered full-term live babies. None of the pregnant women died and there was no abortion, stillbirth or congenital abnormalities in the newborn babies.

Plasmodium falciparum: adherence of the parasite-infected erythrocytes to chondroitin sulfate proteoglycans bearing structurally distinct chondroitin sulfate chains

Infection with Plasmodium falciparum during pregnancy leads to the selective adherence of infected red blood cells (IRBCs) in the placenta causing placental malaria. The IRBC adherence is mediated through the chondroitin 4-sulfate (C4S) chains of unusually low-sulfated chondroitin sulfate proteoglycans (CSPGs) in the placenta. To study the structural interactions involved in C4S-IRBC adherence, various investigators have used CSPGs from different sources. Since the structural characteristics of the polysaccharide chains in CSPGs from various sources differ substantially, the CSPGs are likely to differentially bind IRBCs. In this study, the CSPG purified from bovine trachea, a CSPG form of human recombinant thrombomodulin (TM-CSPG), two CSPG fractions from bovine cornea, and the CSPGs of human placenta, the natural receptor, were studied in parallel for their IRBC binding characteristics. The TM-CSPG and corneal CSPG fractions could bind IRBCs at significantly higher density compared to the placental CSPGs. However, the avidity of IRBC binding by TM-CSPG was considerably low compared to placental CSPGs. The corneal CSPGs have substantially higher binding strengths. The bovine tracheal CSPG bound IRBCs at much lower density and exhibited significantly lower avidity than the placental CSPGs. These data demonstrated that the bovine tracheal CSPG and TM-CSPG are not ideal for studying the fine structural interactions involved in the IRBC adherence to the placental C4S, whereas the bovine corneal CSPGs are better alternatives to the placental CSPGs for determining these interactions.

Distribution of causes of maternal mortality during delivery and post-partum: results of an African multicentre hospital-based study

OBJECTIVE

To assess the maternal mortality ratio in maternity units of reference hospitals in large west African cities, and to describe the distribution of complications and causes of maternal deaths.

STUDY DESIGN

Prospective descriptive study in twelve reference maternities located in three African countries (Benin, Ivory Coast, Senegal). Data (clinical findings at hospital entry, medical history, complications, type of surgery, vital status of the women at discharge) were collected from obstetrical and surgical files and from admission hospital registers. All cases of maternal deaths were systematically reviewed by African and European staff.

RESULTS

Of a total of 10,515 women, 1495 presented a major obstetric complication with dystocia or inappropriate management of the labour phase as the leading cause. Eighty-five maternal deaths were reported, giving a global hospital-based maternal mortality ratio of 800/100,000. Hypertensive disorders were involved in 25/85 cases (29%) and post-partum haemorrhage in 13/85 cases (15%). Relatively few cases (14) of major sepsis were reported, leading to three maternal deaths.

CONCLUSION

The results of this multicentre study confirm the high rates of maternal mortality in maternity units of reference hospitals in large African cities, and in addition to dystocia the contribution of hypertensive disorders and post-partum haemorrhage to maternal deaths.