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1.  Maternal mortality at muhimbili national hospital in Dar-es-Salaam, Tanzania in the year 2011 
Background
Improving maternal health is one of the eight millennium development goals adopted at the millennium summit in the year 2000. Within this frame work, the international community is committed to reduce the maternal mortality ratio by 75% between 1990 and 2015. The objective of this study was to determine the maternal mortality ratio, classify causes of maternal deaths and assess substandard care factors at Muhimbili National Hospital (MNH), Dar-es-Salaam in Tanzania.
Methods
A retrospective review of all maternal death records of cases that occurred from 1st January to 31st December 2011 was done.
Results
There were 10,057 live births, 155 maternal deaths and hence MMR of 1,541 per 100,000 live births. Direct causes of maternal deaths were classified in 69.5% of the maternal deaths. Of the direct causes, preeclampsia/eclampsia was the major cause (19.9% of all deaths), followed by post partum haemorrhage (14.9%), abortion complications (9.9%) and sepsis (9.2%). Among the indirect causes anaemia was the leading cause (11.3%) of all deaths, followed by HIV/AIDS (9.9%). Substandard care factors contributing to deaths were identified in 116 (82.3%) of all cases. Among these 28 had patient factors only, 71 medical service factors while 17 had both patient and medical service substandard care factors. The common factors from the woman’s side included delay in seeking care (73.3%) and complete lack of antenatal care (11.1%). Of the medical service factors, inadequate (26.1%) or no blood for transfusion (19.3%), delay in receiving treatment (18.3%) and mismanagement (17%) were the common factors.
Conclusion
There is a high maternal mortality ratio at MNH. Hypertensive disorders of pregnancy, post partum haemorrhage and anaemia are the leading causes of maternal deaths in this institution. Multiple substandard care factors identified both at individual and health care service levels that contributed to maternal deaths. There is a need for increasing efforts in the fight to reduce maternal deaths at the institution. A more pro-active role from the referring facilities in the region is needed.
doi:10.1186/1471-2393-14-320
PMCID: PMC4174678  PMID: 25217326
2.  Assessing post-abortion care in health facilities in Afghanistan: a cross-sectional study 
Background
Complications of abortion are one of the leading causes of maternal mortality worldwide, along with hemorrhage, sepsis, and hypertensive diseases of pregnancy. In Afghanistan little data exist on the capacity of the health system to provide post-abortion care (PAC). This paper presents findings from a national emergency obstetric and neonatal care needs assessment related to PAC, with the aim of providing insight into the current situation and recommendations for improvement of PAC services.
Methods
A national Emergency Obstetric and Neonatal Care Needs Assessment was conducted from December 2009 through February 2010 at 78 of the 127 facilities designated to provide emergency obstetric and neonatal care services in Afghanistan. Research tools were adapted from the Averting Maternal Death and Disability Program Needs Assessment Toolkit and national midwifery education assessment tools. Descriptive statistics were used to summarize facility characteristics, and linear regression models were used to assess the factors associated with providers’ PAC knowledge and skills.
Results
The average number of women receiving PAC in the past year in each facility was 244, with no significant difference across facility types. All facilities had at least one staff member who provided PAC services. Overall, 70% of providers reported having been trained in PAC and 68% felt confident in their ability to perform these services. On average, providers were able to identify 66% of the most common complications of unsafe or incomplete abortion and 57% of the steps to take in examining and managing women with these complications. Providers correctly demonstrated an average of 31% of the tasks required for PAC during a simulated procedure. Training was significantly associated with PAC knowledge and skills in multivariate regression models, but other provider and facility characteristics were not.
Conclusions
While designated emergency obstetric facilities in Afghanistan generally have most supplies and equipment for PAC, the capacity of healthcare providers to deliver PAC is limited. Therefore, we strongly recommend training all skilled birth attendants in PAC services. In addition, a PAC training package should be integrated into pre-service medical education.
Electronic supplementary material
The online version of this article (doi:10.1186/s12884-015-0439-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12884-015-0439-x
PMCID: PMC4320442  PMID: 25645657
Post-abortion care; Emergency obstetric and neonatal care; Afghanistan
3.  The development of quality indicators for the prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands 
Background
At present, there are no guidelines on prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands. The first step towards implementing guidelines is the development of a set of quality indicators for prevention and management of postpartum haemorrhage for primary midwifery supervised (home) birth in the Netherlands.
Methods
A RAND modified Delphi procedure was applied. This method consists of five steps: (1) composing an expert panel (2) literature research and collection of possible quality indicators, (3) digital questionnaire, (4) consensus meeting and (5) critical evaluation. A multidisciplinary expert panel consisting of five midwives, seven obstetricians and an ambulance paramedic was assembled after applying pre-specified criteria concerning expertise in various domains relating to primary midwifery care, secondary obstetric care, emergency transportation, maternal morbidity or mortality audit, quality indicator development or clinical guidelines development and representatives of professional organisations.
Results
After literature review, 79 recommendations were selected for assessment by the expert panel. After a digital questionnaire to the expert panel seven indicators were added, resulting in 86 possible indicators. After excluding 41 indicators that panel members unanimously found invalid, 45 possible indicators were assessed at the consensus meeting. During critical evaluation 18 potential indicators were found to be overlapping and two were discarded due to lack of measurability.
Conclusions
A set of 25 quality indicators was considered valid for testing in practice.
doi:10.1186/1471-2393-13-194
PMCID: PMC4016500  PMID: 24139411
Quality indicators; Postpartum haemorrhage; Midwifery; Delphi technique; Home birth; The Netherlands
4.  Postpartum haemorrhage in midwifery care in the Netherlands: validation of quality indicators for midwifery guidelines 
Background
Postpartum haemorrhage (PPH) is still one of the major causes of severe maternal morbidity and mortality worldwide. Currently, no guideline for PPH occurring in primary midwifery care in the Netherlands is available. A set of 25 quality indicators for prevention and management of PPH in primary care has been developed by an expert panel consisting of midwives, obstetricians, ambulance personal and representatives of the Royal Dutch College of Midwives (KNOV) and the Dutch Society of Obstetrics and Gynecology (NVOG). This study aims to assess the performance of these quality indicators as an assessment tool for midwifery care and suitability for incorporation in a professional midwifery guideline.
Methods
From April 2008 to April 2010, midwives reported cases of PPH. Cases were assessed using the 25 earlier developed quality indicators. Quality criteria on applicability, feasibility, adherence to the indicator, and the indicator’s potential to monitor improvement were assessed.
Results
98 cases of PPH were reported during the study period, of which 94 were analysed. Eleven indicators were found to be applicable and feasible. Five of these indicators showed improvement potential: routine administration of uterotonics, quantifying blood loss by weighing, timely referral to secondary care in homebirth and treatment of PPH using catherisation, uterine massage and oxytocin and the use of oxygen.
Conclusions
Eleven out of 25 indicators were found to be suitable as an assessment tool for midwifery care of PPH and are therefore suitable for incorporation in a professional midwifery guideline. Larger studies are necessary to confirm these results.
doi:10.1186/s12884-014-0397-8
PMCID: PMC4266235  PMID: 25481692
Post-partum hemorrhage; Home birth; Primary care; Midwifery; Quality indicators
5.  Prevention and management of severe pre-eclampsia/eclampsia in Afghanistan 
Background
An evidence-based strategy exists to reduce maternal morbidity and mortality associated with severe pre-eclampsia/eclampsia (PE/E), but it may be difficult to implement in low-resource settings. This study examines whether facilities that provide emergency obstetric and newborn care (EmONC) in Afghanistan have the capacity to manage severe PE/E cases.
Methods
A further analysis was conducted of the 2009–10 Afghanistan EmONC Needs Assessment. Assessors observed equipment and supplies available, and services provided at 78 of the 127 facilities offering comprehensive EmONC services and interviewed 224 providers. The providers also completed a written case scenario on severe PE/E. Descriptive statistics were used to summarize facility and provider characteristics. Student t-test, one-way ANOVA, and chi-square tests were performed to determine whether there were significant differences between facility types, doctors and midwives, and trained and untrained providers.
Results
The median number of severe PE/E cases in the past year was just 5 (range 0–42) at comprehensive health centers (CHCs) and district hospitals, compared with 44 (range 0–130) at provincial hospitals and 108 (range 32–540) at regional and specialized hospitals (p < 0.001). Most facilities had the drugs and supplies needed to treat severe PE/E, including the preferred anticonvulsant, magnesium sulfate (MgSO4). One-third of the smallest facilities and half of larger facilities reported administering a second-line drug, diazepam, in some cases. In the case scenario, 96% of doctors and 89% of midwives recognized that MgSO4 should be used to manage severe PE/E, but 42% of doctors and 58% of midwives also thought diazepam had a role to play. Providers who were trained on the use of MgSO4 scored significantly higher than untrained providers on six of 20 items in the case scenario. Providers at larger facilities significantly outscored those at smaller facilities on five items. There was a significant difference between doctors and midwives on only one item: continued use of anti-hypertensives after convulsions are controlled.
Conclusions
Drugs and supplies needed to treat severe PE/E are widely available at EmONC facilities in Afghanistan, but providers lack knowledge in some areas, especially concerning the use of MgSO4 and diazepam. Providers who have specialized training or work at larger facilities are better at managing cases of severe PE/E. The findings suggest a need to clarify service delivery guidelines, offer refresher training, and reinforce best practices with supervision and reinforcement.
doi:10.1186/1471-2393-13-186
PMCID: PMC3852136  PMID: 24119329
Pre-eclampsia; Eclampsia; Magnesium sulfate; Emergency obstetric care; Afghanistan
6.  Local health workers’ perceptions of substandard care in the management of obstetric hemorrhage in rural Malawi 
Background
To identify factors contributing to the high incidence of facility-based obstetric hemorrhage in Thyolo District, Malawi, according to local health workers.
Methods
Three focus group discussions among 29 health workers, including nurse-midwives and non-physician clinicians (‘medical assistants’ and ‘clinical officers’).
Results
Factors contributing to facility-based obstetric hemorrhage mentioned by participants were categorized into four major areas: (1) limited availability of basic supplies, (2) lack of human resources, (3) inadequate clinical skills of available health workers and (4) substandard referrals by traditional birth attendants and lack of timely self-referrals of patients.
Conclusion
Health workers in this district mentioned important community, system and provider related factors that need to be addressed in order to reduce the impact of obstetric hemorrhage.
doi:10.1186/1471-2393-13-39
PMCID: PMC3583700  PMID: 23414077
7.  The quality of antenatal care in rural Tanzania: what is behind the number of visits? 
Background
Antenatal care (ANC) provides an important opportunity for pregnant women with a wide range of interventions and is considered as an important basic component of reproductive health care.
Methods
In 2008, severe maternal morbidity audit was established at Saint Francis Designated District Hospital (SFDDH), in Kilombero district in Tanzania, to ascertain substandard care and implement interventions. In addition, a cross-sectional descriptive study was carried out in 11 health facilities within the district to assess the quality of ANC and underlying factors in a broader view.
Results
Of 363 severe maternal morbidities audited, only 263 (72%) ANC cards were identified. Additionally, 121 cards (with 299 ANC visits) from 11 facilities were also reviewed. Hemoglobin and urine albumin were assessed in 22% – 37% and blood pressure in 69% - 87% of all visits. Fifty two (20%) severe maternal morbidities were attributed to substandard ANC, of these 39 had severe anemia and eclampsia combined. Substandard ANC was mainly attributed to shortage of staff, equipment and consumables. There was no significant relationship between assessment of essential parameters at first ANC visit and total number of visits made (Spearman correlation coefficient, r = 0.09; p = 0.13). Several interventions were implemented and others were proposed to those in control of the health system.
Conclusions
This article reflects a worrisome state of substandard ANC in rural Tanzania resulting from inadequate human workforce and material resources for maternal health, and its adverse impacts on maternal wellbeing. These results suggest urgent response from those in control of the health system to invest more resources to avert the situation in order to enhance maternal health in this country.
doi:10.1186/1471-2393-12-70
PMCID: PMC3434089  PMID: 22823930
8.  Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change 
Background
The burden of maternal mortality in resource limited countries is still huge despite being at the top of the global public health agenda for over the last 20 years. We systematically reviewed the impacts of interventions on maternal health and factors for change in these countries.
Methods
A systematic review was carried out using the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles published in the English language reporting on implementation of interventions, their impacts and underlying factors for maternal health in resource limited countries in the past 23 years were searched from PubMed, Popline, African Index Medicus, internet sources including reproductive health gateway and Google, hand-searching, reference lists and grey literature.
Results
Out of a total of 5084 articles resulting from the search only 58 qualified for systematic review. Programs integrating multiple interventions were more likely to have significant positive impacts on maternal outcomes. Training in emergency obstetric care (EmOC), placement of care providers, refurbishment of existing health facility infrastructure and improved supply of drugs, consumables and equipment for obstetric care were the most frequent interventions integrated in 52% - 65% of all 54 reviewed programs. Statistically significant reduction of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the programs respectively. Births in EmOC facilities and caesarean section rates increased significantly in 71% - 75% of programs using these indicators. Insufficient implementation of evidence-based interventions in resources limited countries was closely linked to a lack of national resources, leadership skills and end-users factors.
Conclusions
This article presents a list of evidenced-based packages of interventions for maternal health, their impacts and factors for change in resource limited countries. It indicates that no single magic bullet intervention exists for reduction of maternal mortality and that all interventional programs should be integrated in order to bring significant changes. State leaders and key actors in the health sectors in these countries and the international community are proposed to translate the lessons learnt into actions and intensify efforts in order to achieve the goals set for maternal health.
doi:10.1186/1471-2393-11-30
PMCID: PMC3090370  PMID: 21496315
9.  Amniotic fluid embolism incidence, risk factors and outcomes: a review and recommendations 
Background
Amniotic fluid embolism (AFE) is a rare but severe complication of pregnancy. A recent systematic review highlighted apparent differences in the incidence, with studies estimating the incidence of AFE to be more than three times higher in North America than Europe. The aim of this study was to examine population-based regional or national data from five high-resource countries in order to investigate incidence, risk factors and outcomes of AFE and to investigate whether any variation identified could be ascribed to methodological differences between the studies.
Methods
We reviewed available data sources on the incidence of AFE in Australia, Canada, the Netherlands, the United Kingdom and the USA. Where information was available, the risk factors and outcomes of AFE were examined.
Results
The reported incidence of AFE ranged from 1.9 cases per 100 000 maternities (UK) to 6.1 per 100 000 maternities (Australia). There was a clear distinction between rates estimated using different methodologies. The lowest estimated incidence rates were obtained through validated case identification (range 1.9-2.5 cases per 100 000 maternities); rates obtained from retrospective analysis of population discharge databases were significantly higher (range 5.5-6.1 per 100 000 admissions with delivery diagnosis). Older maternal age and induction of labour were consistently associated with AFE.
Conclusions
Recommendation 1: Comparisons of AFE incidence estimates should be restricted to studies using similar methodology. The recommended approaches would be either population-based database studies using additional criteria to exclude false positive cases, or tailored data collection using existing specific population-based systems.
Recommendation 2: Comparisons of AFE incidence between and within countries would be facilitated by development of an agreed case definition and an agreed set of criteria to minimise inclusion of false positive cases for database studies.
Recommendation 3: Groups conducting detailed population-based studies on AFE should develop an agreed strategy to allow combined analysis of data obtained using consistent methodologies in order to identify potentially modifiable risk factors.
Recommendation 4: Future specific studies on AFE should aim to collect information on management and longer-term outcomes for both mothers and infants in order to guide best practice, counselling and service planning.
doi:10.1186/1471-2393-12-7
PMCID: PMC3305555  PMID: 22325370
10.  Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania 
Background
Although clinical audit is an important instrument for quality care improvement, the concept has not yet been adequately taken on board in rural settings in most resource limited countries where the problem of maternal mortality is immense. Maternal mortality and morbidity audit was established at Saint Francis Designated District Hospital (SFDDH) in rural Tanzania in order to generate information upon which to base interventions.
Methods
Methods are informed by the principles of operations research. An audit system was established, all patients fulfilling the inclusion criteria for maternal mortality and severe morbidity were reviewed and selected cases were audited from October 2008 to July 2010. The causes and underlying factors were identified and strategic action plans for improvement were developed and implemented.
Results
There were 6572 deliveries and 363 severe maternal morbidities of which 36 women died making institutional case fatality rate of 10%. Of all morbidities 341 (94%) had at least one area of substandard care. Patients, health workers and administration related substandard care factors were identified in 50% - 61% of women with severe morbidities. Improving responsiveness to obstetric emergencies, capacity building of the workforce for health care, referral system improvement and upgrading of health centres located in hard to reach areas to provide comprehensive emergency obstetric care (CEmOC) were proposed and implemented as a result of audit.
Conclusions
Our findings indicate that audit can be implemented in rural resource limited settings and suggest that the vast majority of maternal mortalities and severe morbidities can be averted even where resources are limited if strategic interventions are implemented.
doi:10.1186/1471-2393-11-94
PMCID: PMC3226647  PMID: 22088168
11.  Factors for change in maternal and perinatal audit systems in Dar es Salaam hospitals, Tanzania 
Background
Effective maternal and perinatal audits are associated with improved quality of care and reduction of severe adverse outcome. Although audits at the level of care were formally introduced in Tanzania around 25 years ago, little information is available about their existence, performance, and practical barriers to their implementation. This study assessed the structure, process and impacts of maternal and perinatal death audit systems in clinical practice and presents a detailed account on how they could be improved.
Methods
A cross sectional descriptive study was conducted in eight major hospitals in Dar es Salaam in January 2009. An in-depth interview guide was used for 29 health managers and members of the audit committees to investigate the existence, structure, process and outcome of such audits in clinical practice. A semi-structured questionnaire was used to interview 30 health care providers in the maternity wards to assess their awareness, attitude and practice towards audit systems. The 2007 institutional pregnancy outcome records were reviewed.
Results
Overall hospital based maternal mortality ratio was 218/100,000 live births (range: 0 - 385) and perinatal mortality rate was 44/1000 births (range: 17 - 147). Maternal and perinatal audit systems existed only in 4 and 3 hospitals respectively, and key decision makers did not take part in audit committees. Sixty percent of care providers were not aware of even a single action which had ever been implemented in their hospitals because of audit recommendations. There were neither records of the key decision points, action plan, nor regular analysis of the audit reports in any of the facilities where such audit systems existed.
Conclusions
Maternal and perinatal audit systems in these institutions are poorly established in structure and process; and are less effective to improve the quality of care. Fundamental changes are urgently needed for successful audit systems in these institutions.
doi:10.1186/1471-2393-10-29
PMCID: PMC2896922  PMID: 20525282
12.  Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania 
Background
Perinatal death is a devastating experience for the mother and of concern in clinical practice. Regular perinatal audit may identify suboptimal care related to perinatal deaths and thus appropriate measures for its reduction. The aim of this study was to perform a qualitative perinatal audit of intrapartum and early neonatal deaths and propose means of reducing the perinatal mortality rate (PMR).
Methods
From 1st August, 2007 to 31st December, 2007 we conducted an audit of perinatal deaths (n = 133) with birth weight 1500 g or more at Muhimbili National Hospital (MNH). The audit was done by three obstetricians, two external and one internal auditors. Each auditor independently evaluated the cases narratives. Suboptimal factors were identified in the antepartum, intrapartum and early neonatal period and classified into three levels of delay (community, infrastructure and health care). The contribution of each suboptimal factor to adverse perinatal outcome was identified and the case graded according to possible avoidability. Degree of agreement between auditors was assessed by the kappa coefficient.
Results
The PMR was 92 per 1000 total births. Suboptimal factors were identified in 80% of audited cases and half of suboptimal factors were found to be the likely cause of adverse perinatal outcome and were preventable. Poor foetal heart monitoring during labour was indirectly associated with over 40% of perinatal death. There was a poor to fair agreement between external and internal auditors.
Conclusion
There are significant areas of care that need improvement. Poor monitoring during labour was a major cause of avoidable perinatal mortality. This type of audit was a good starting point for quality assurance at MNH. Regular perinatal audits to identify avoidable causes of perinatal deaths with feed back to the staff may be a useful strategy to reduce perinatal mortality.
doi:10.1186/1471-2393-9-45
PMCID: PMC2754979  PMID: 19765312
13.  Caesarean section in a semi-rural hospital in Northern Namibia 
Background
Increasing caesarean sections rates (CSR) are a major public health concern and the prevention of the first caesarean section, which often leads to repeat operations, is an important issue. Analyzing caesarean sections can help to identify factors associated with variations in CSR and help to assess the quality of clinical care.
Methods
In a retrospective observational study, during a two year period, indications of 576 caesarean sections were analyzed using intra-operative internal pelvimetry and a record keeping system in a semi-rural hospital in Northern Namibia.
Results
Most caesarean sections were done for dystocia (34%) followed by repeat caesarean section (31%). The true conjugate (distance between the promontorium to mid pubic bone) was significantly smaller in these recurrent indication groups when compared to non recurrent indications.
Conclusion
In this rural hospital the introduction of Delee Pelvimetry and a caesarean section record keeping system was found to be a simple and cheap method to analyse indications for caesarean sections, which may help in reducing unnecessary caesarean sections.
doi:10.1186/1471-2393-7-2
PMCID: PMC1821336  PMID: 17346332

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