Direct Obstetric Complications Research Articles

Provision of emergency obstetric care at secondary level in a conflict setting in a rural area of Afghanistan \u2013 is the hospital fulfilling its role?

BackgroundProvision of Emergency Obstetric and Neonatal Care (EmONC) reduces maternal mortality and should include three components: Basic Emergency Obstetric and Neonatal Care (BEmONC) offered at primary care level, Comprehensive EmONC (CEmONC) at secondary level and a good referral system in-between. In a conflict-affected province of Afghanistan (Khost), we assessed the performance of an Médecins Sans Frontières (MSF) run CEmONC hospital without a primary care and referral system. Performance was assessed in terms of hospital utilisation for obstetric emergencies and quality of obstetric care.MethodsA cross-sectional study using routine programme data (2013–2014).ResultsOf 29,876 admissions, 99% were self-referred, 0.4% referred by traditional birth attendants and 0.3% by health facilities. Geographic origins involved clustering around the hospital vicinity and the provincial road axis. While there was a steady increase in hospital caseload, the number and proportion of women with Direct Obstetric Complications (DOC) progressively dropped from 21% to 8% over 2 years. Admissions for normal deliveries continuously increased. In-hospital maternal deaths were 0.03%, neonatal deaths 1% and DOC case-fatality rate 0.2% (all within acceptable limits).ConclusionsDespite a high and ever increasing caseload, good quality Comprehensive EmONC could be offered in a conflict-affected setting in rural Afghanistan. However, the primary emergency role of the hospital is challenged by diversion of resources to normal deliveries that should happen at primary level. Strengthening Basic EmONC facilities and establishing an efficient referral system are essential to improve access for emergency cases and increase the potential impact on maternal mortality.

Validity of a minimally invasive autopsy for cause of death determination in maternal deaths in Mozambique: An observational study.

BackgroundDespite global health efforts to reduce maternal mortality, rates continue to be unacceptably high in large parts of the world. Feasible, acceptable, and accurate postmortem sampling methods could provide the necessary evidence to improve the understanding of the real causes of maternal mortality, guiding the design of interventions to reduce this burden.Methods and findingsThe validity of a minimally invasive autopsy (MIA) method in determining the cause of death was assessed in an observational study in 57 maternal deaths by comparing the results of the MIA with those of the gold standard (complete diagnostic autopsy [CDA], which includes any available clinical information). Concordance between the MIA and the gold standard diagnostic categories was assessed by the kappa statistic, and the sensitivity, specificity, positive and negative predictive values and their 95% confidence intervals (95% CI) to identify the categories of diagnoses were estimated. The main limitation of the study is that both the MIA and the CDA include some degree of subjective interpretation in the attribution of cause of death.A cause of death was identified in the CDA in 98% (56/57) of cases, with indirect obstetric conditions accounting for 32 (56%) deaths and direct obstetric complications for 24 (42%) deaths. Nonobstetric infectious diseases (22/32, 69%) and obstetric hemorrhage (13/24, 54%) were the most common causes of death among indirect and direct obstetric conditions, respectively. Thirty-six (63%) women were HIV positive, and HIV-related conditions accounted for 16 (28%) of all deaths. Cerebral malaria caused 4 (7%) deaths. The MIA identified a cause of death in 86% of women. The overall concordance of the MIA with the CDA was moderate (kappa = 0.48, 95% CI: 0.31–0.66). Both methods agreed in 68% of the diagnostic categories and the agreement was higher for indirect (91%) than for direct obstetric causes (38%). All HIV infections and cerebral malaria cases were identified in the MIA. The main limitation of the technique is its relatively low performance for identifying obstetric causes of death in the absence of clinical information.ConclusionsThe MIA procedure could be a valuable tool to determine the causes of maternal death, especially for indirect obstetric conditions, most of which are infectious diseases.The information provided by the MIA could help to prioritize interventions to reduce maternal mortality and to monitor progress towards achieving global health targets.

Determinants of pre-eclampsia/Eclampsia among women attending delivery Services in Selected Public Hospitals of Addis Ababa, Ethiopia: a case control study

BackgroundPre-eclampsia is a pregnancy-specific hypertensive disorder usually occurs after 20 weeks of gestation. It is one of the leading causes of maternal and perinatal morbidity and mortality worldwide. In Ethiopia, the major direct obstetric complications including pre-eclampsia/eclampsia account for 85% of the maternal deaths. Unlike deaths due to other direct causes, pre-eclampsia/ eclampsia related deaths appear to be increasing and linked to multiple factors, making prevention of the disease a continuous challenge. The aim of this study is to assess determinants of pre-eclampsia/eclampsiaamong women attending delivery services in selected public hospitals in Addis Ababa, Ethiopia.MethodsHospital based unmatched case control study design was employed. The study wasconducted in Addis Ababa among women attending delivery services in two public hospitals from December, 2015 G.C. to February, 2016 G.C. with sample size of 291 (97 cases and 194 controls). Women with pre-eclampsia/eclampsia were cases and women who had not diagnosed for pre-eclampsia/eclampsia were controls. Case-control incidence density sampling followed by interviewer administered was conducted using pretested questionnaire. The data was entered in Epi Info 7 software and exported to STATA 14 for cleaning and analysis. Descriptive statistics were used todisplay the data using tables compared between cases and controls. To compare categorical variables between cases and controls Chi-squared testwas used. Both bivariable and multivariable logistic regression analyses were computed to identify the determinants of pre-eclampsia/eclampsia.ResultsFactors that were found to have statistically significant association with pre-eclampsia or eclampsia were primigravida (AOR: 2.68, 95% CI: 1.38, 5.22), history of preeclampsia on prior pregnancy (AOR: 4.28, 95% CI: 1.61, 11.43), multiple pregnancy (AOR: 8.22, 95% CI: 2.97, 22.78), receiving nutritional counseling during pregnancy (AOR: 0.22, 95% CI: 0.1, 0.48) and drinking alcohol during pregnancy (AOR: 3.97, 95% CI: 1.8, 8.75).ConclusionsThe study identified protective and risk factors for pre-eclampsia/eclampsia. To promptly diagnose and treat pre-eclampsia, health workers should give special attention to women with primigravida and multiple pregnancy. Besides, health care providers should provide nutritional counseling during ANC, including avoiding drinking alcohol during their pregnancy.

Consequences of maternal morbidity on health-related functioning: a systematic scoping review

ObjectivesTo assess the scope of the published literature on the consequences of maternal morbidity on health-related functioning at the global level and identify key substantive findings as well as research...

The status of maternal and newborn health care services in Zanzibar.

BackgroundIt is estimated that 287,000 women worldwide die annually from pregnancy and childbirth-related conditions, and 6.9 million under-five children die each year, of which about 3 million are newborns. Most of these deaths occur in sub-Saharan Africa. The maternal health situation in Tanzania mainland and Zanzibar is similar to other sub-Saharan countries. This study assessed the availability, accessibility and quality of emergency obstetric care services and essential resources available for maternal and child health services in Zanzibar.MethodsFrom October and November 2012, a cross-sectional health facility survey was conducted in 79 health facilities in Zanzibar. The health facility tools developed by the Averting Maternal Death and Disability program were adapted for local use.ResultsOnly 7.6 % of the health facilities qualified as functioning basic EmONC (Emergency Obstetric and Neonatal Care) facilities and 9 % were comprehensive EmONC facilities. Twenty-eight percent were partially performing basic EmONC and the remaining 55.7 % were not providing EmONC. Neonatal resuscitation was performed in 80 % of the hospitals and only 17.4 % of the other health facilities that were surveyed. Based on World Health Organisation (WHO) criteria, the study revealed a gap of 20 % for minimum provision of EmONC facilities per 500,000 population. The met need at national level (proportion of women with major direct obstetric complications treated in a health facility providing EmONC) was only 33.1 % in the 12 months preceding the survey. The study found that there was limited availability of human resources in all visited health facilities, particularly for the higher cadres, as per Zanzibar minimum staff requirements.ConclusionThere is a need to strengthen human resource capacity at primary health facilities through training of health care providers to improve EmONC services, as well as provision of necessary equipment and supplies to reduce workload at the higher referral health facilities and increase geographic access.

Maternal and Perinatal Mortality in the 21st Century

ABSTRACT The maternal mortality ratio measures how safe it is to become pregnant and give birth in a geographic area or a population. The total number of maternal deaths observed annually fell from 526,000 in 1980 to 358,000 in 2008, a 34% decline over this period. Similarly, the global MMR declined from 422 in 1980 to 320 in 1990 and was 250 per 100,000 live births in 2008, a decline of 34% over the entire period and an average annual decline of 2.3%. More specifically, in 1990 around 58% of maternal deaths worldwide occurred in Asia and 36% in sub-Saharan Africa. In contrast, in 2008, 57% of global maternal deaths occurred in sub-Saharan Africa and 39% in Asia. In Europe, the main causes of death from any known direct obstetric complication remains bleeding (13%), thromboembolic events (10.1%), complicationassociated birth, hypertensive disease of pregnancy (9.2%), and amniotic fluid embolism (10.6%). Preterm birth is the most common cause of perinatal mortality (PNM) causing almost 30% of neonatal deaths, while birth defects cause about 21% of neonatal deaths. The PNM rate refers to the number of perinatal deaths per 1,000 total births. Perinatal mortality rate may be below 10 for certain developed countries and more than 10 times higher in developing countries. Perinatal health in Europe has improved dramatically in recent decades. In 1975, neonatal mortality ranged from 7 to 27 per 1,000 live births in the countries that now make up the EU. By 2005, it had declined to 8 per 1,000 live births. We need to bring together data from civil registration, medical birth registers, hospital discharge systems in order to have European Surveys which present exciting research possibilities. How to cite this article Antsaklis A. Maternal and Perinatal Mortality in the 21st Century. Donald School J Ultrasound Obstet Gynecol 2016;10(2):143-146.

Ambulance referral for emergency obstetric care in remote settings.

To evaluate the functionality of an ambulance service dedicated to emergency obstetric care (EmOC) that referred pregnant women to health centers for delivery assistance or to a hospital for the management of obstetric complications. A retrospective study investigated an ambulance referral system for EmOC in a rural area of Ethiopia between July 1 and December 31, 2013. The service was available 24h a day and was free of charge. Women requesting referral were transported to nearby health centers. Assistance was provided locally for uncomplicated deliveries. Women with obstetric complications were referred from health centers to a hospital. A total of 528 ambulance referrals were recorded. The majority of patients (314 [59.5%]) were transported from villages to health centers. The remaining individuals were brought to a hospital, having been referred from health centers (179 [33.9%]) or were referred directly from villages owing to hospital proximity (35 [6.6%]). Of the 179 patients referred to the hospital from health centers, 84 (46.9%) were diagnosed with major direct obstetric complications. No maternal deaths were recorded among patients using the ambulance service. The cost of the ambulance service was US$ 18.47 per referred patient. An ambulance service dedicated to EmOC that interconnected health centers and a hospital facilitated referrals and better utilized local resources.

Availability and Quality of Emergency Obstetric and Newborn Care Service in Dire Dawa, Ethiopia

Background: Emergency and new born care service (EmONC) is a package of medical interventions that treat the direct obstetric complications. Aim: To assess the availability and quality of emergency obstetric and new born care service in Dire Dawa town health facilities. Methods: Institution based cross sectional study was carried out on emergency obstetric and new born care (EmONC) service in Dire Dawa town of Eastern Ethiopia. All 15 health facilities were assessed. Data was collected using a standard check list that was adopted from WHO, UNICEF AND UNFPA emergency obstetric monitoring handbook and Engenderhealth emergency obstetric quality improvement assessment tool. The data were cleaned, coded and entered into SPSS version 20 for descriptive analysis. Results: Out of 5 hospitals and 1 higher private clinic that were expected to offer comprehensive emergency obstetric and new born care (CEmONC) service, 1 was qualified as CEmONC health facility. Out of 9 health centers that are expected to offer basic emergency obstetrics and new born care (BEmONC) service, 1 was qualified as BEmONC facility. Case fatality rate and population based caesarean section rate were 5.3% and 11.4% respectively. The most frequent direct obstetric complication was severe preeclampsia/eclampsia accounting for 36.6% (117/320). It was also the cause of almost one third of maternal deaths (5/17). Conclusions: BEmONC facility ratio was not adequate while CEmONC facility ratio met the minimum standard. Case fatality rate (CFR) is higher than what is recommended by the UN, which indicates poor quality of EmONC service.

Risk factors for stillbirths in Tete, Mozambique

ObjectiveTo evaluate known risk factors for stillbirth and identify local priorities for stillbirth prevention among institutional deliveries in Tete, Mozambique. MethodsA case–control study was conducted among 150 women who experienced stillbirths and 300 women who experienced live deliveries at three health facilities between December 1, 2009, and April 30, 2011. Case and control individuals were matched for health facility, age, and parity. Sociodemographic, pregnancy, and delivery characteristics (including HIV and syphilis serology) were assessed. Bivariate associations and a conditional logistic regression model identified variables contributing to fetal outcome. ResultsNo between-group differences were recorded in the frequency of infection with HIV (25 [16.7%] cases vs 55 [18.3%] controls; P=0.663) or syphilis (6 [4.0%] vs 16 [5.3%]; P=0.536) at delivery. Multivariate analysis revealed that stillbirth was associated with direct obstetric complications (mutually adjusted odds ratio [OR] 6.7; 95% confidence interval [CI] 3.6–12.1), low socioeconomic status (mutually adjusted OR 1.8; 95% CI 1.1–3.1), and referral during childbirth (mutually adjusted OR 3.2; 95% CI 1.7–6.1). ConclusionStillbirths in Tete, Mozambique, were predominantly caused by direct obstetric complications requiring referral among women of low socioeconomic status. Prenatal management of HIV and syphilis limited effects on fetal outcome. Emergency obstetric care and referral systems should be the focus of interventions aimed at stillbirth prevention.

Availability, utilization, and quality of emergency obstetric care services in Bauchi State, Nigeria

ObjectiveTo report the availability, utilization, and quality of emergency obstetric care (EmOC) services in Bauchi State, Nigeria. MethodsBetween June and July 2012, a cross-sectional survey of health facilities was conducted. Data on the performance of EmOC services between June 2011 and May 2012 were obtained from records of 20 general hospitals and 39 primary healthcare centers providing delivery services. Additionally, structured interviews with facility managers were conducted. ResultsOnly 6 (10.2%) of the 59 facilities met the UN requirements for EmOC centers. None of the three senatorial zones in Bauchi State had the minimum acceptable number of five EmOC facilities per 500 000 population. Overall, 10 517 (4.4%) of the estimated 239 930 annual births took place in EmOC facilities. Cesarean delivery accounted for 3.6% (n=380) of the 10 517 births occurring in EmOC facilities and 0.2% of the 239 930 expected live births. Only 1416 (3.9%) of the expected 35 990 obstetric complications were managed in EmOC facilities. Overall, 45 (3.2%) of 1416 women with major direct obstetric complications treated at EmOC facilities died. Among 379 maternal deaths, 317 (83.6%) were attributable to major direct obstetric complications. ConclusionAvailability, utilization, and quality of EmOC services in Bauchi State, Nigeria, are suboptimal. The health system’s capacity to manage emergency obstetric complications needs to be strengthened.

Maternal Mortality among Women Seeking Health Care Services in Kisii Level 5 Hospital

<b>Background</b><b>. </b> Maternal mortality has continued to escalate in Kenya inspite of all the efforts being made by the government, non-governmental organization and the community. The purpose of the study was to establish the antecedent factors predisposing women to maternal death using the three delays model. <b>Methodology:</b> Retrospective 72 maternal death cases which occurred between January 01, 2009 and June 30, 2010 were reviewed by an independent gynecologist/obstetrician. Interviews were conducted with kins of the deceased women using a confidential questionnaire for female death based on distal as well as proximal factors that may have had a bearing on maternal death. Health care workers were likewise interviewed using a formulated questionnaire to assess the ability and readiness of the hospital to offer emergency obstetric care. <b>Results:</b> A record of 72 maternal deaths occurred during the study period thus between January 1, 2009 and June 30. 2010. Out of 72, 42 maternal deaths were as a result of direct obstetric complications which include hemorrhage, post-partum sepsis, pre-eclampsia and abortion. Post partum hemorrhage was the most common complication which contributed to maternal deaths. Again out of 72 maternal deaths, 33 were as a result of indirect causes with peritonitis, heart disease, HIV/AIDS, anemia, and convulsive disorder respectively. Delayed access to transport, lack of money for user fees, and hospital distance were challenges that led to delay in accessing care. Hospital experiences included; delay in service provision by staff, delayed quality emergency obstetric care and delayed care while at the hospital, unavailability of blood for transfusion, and lack of money for drugs, were reported as major challenges which attributed to maternal death. <b>Conclusion:</b> The study suggests maternal mortality occurs as a result of lack of access to quality healthcare facility poor health seeking behavior and poor socio-economic factors.

Do socioeconomic inequalities lead to deceptive measurement of obstetric morbidity in India?

Background: The extent of maternal mortality is an indicator of disparity and inequity in access to appropriate health care and nutrition services throughout a lifetime, and particularly during pregnancy and childbirth. According to WHO, 99% of maternal deaths occur in developing countries. Three quarters of maternal mortalities result from the direct obstetric complications. However, the ambiguity and variability in existing literature on the magnitude of socio-economic inequality in obstetric morbidity is leading to complexity for priority setting in health policy. The present study aims at assessing how far self-reported obstetric morbidity misleads measurement of socio-economic inequalities in India and to assess whether refined inequality measures can help to overcome this problem. Methods: The study has used data from the most recent round of National Family Health Survey (NFHS-3). We have used concentration indices to access the socio-economic inequalities in self-reported obstetric morbidity and later implied regression based decomposition analysis to find out the contributions of socio-economic predictor. Results: Findings reveal that self-reporting obstetric morbidity survey data is potentially misleading in measuring socio-economic differentials with simple bivariate analysis as greater number of obstetric complications persists in socio-economically advantaged groups which may be not true in reality. However, application of sophisticated regression based decomposition analysis demonstrates that, to some extent, we can overcome the problem of measuring socio-economic inequality, as decomposition analysis shows incidence of obstetric complication are greater among disadvantaged groups. Conclusion: Primarily, the inequalities arise from poverty, education and residing in rural areas. However, the contribution of education to the incidence of obstetric morbidity is negative. This could be because of differences in the educational level of women that potentially affects their awareness and understanding about obstetric complications. The findings thus suggest that education is a key determinant of bias in self-reporting obstetric morbidity. Finally, we conclude that logical explanations of the results are needed when we infer these results for health policy interventions, as decomposition analysis has also failed to overcome the problem of self-reporting morbidities among illiterate women.

Epidemiologic profile, survival, and maternal prognosis factors among women at an obstetric intensive care unit

ObjectiveTo identify the epidemiologic profile, maternal survival, and prognosis factors that might affect survival rates in the obstetric intensive care unit (ICU). MethodsA prospective cohort study was conducted between January 2007 and February 2009 in a tertiary referral ICU, Belo Horizonte, Brazil. Critical patients during pregnancy and puerperium were followed from admission until discharge or death. Maternal survival was assessed in association with the cause of ICU admission, grouped into direct or indirect obstetric causes, by Kaplan–Meier curves and log-rank tests. ResultsAmong 298 patients admitted to the ICU during the study period, mortality was 4.7% (n=14). Hypertensive disorders (46.0%), hemorrhage (15.9%), sepsis (14.2%), and heart disease (5.7%) were the main causes of admission. Half of the patients who died were admitted for direct obstetric reasons (n=7). Survival was statistically linked to the cause of admission: most survivors were admitted for a direct obstetric cause (75.5%; P=0.044). Maternal survival rates of patients admitted for indirect obstetric causes were lower than those admitted for direct obstetric causes (27.8 and 19.6days, respectively; P=0.019). ConclusionThe main cause of admission was a decisive factor for maternal survival in the obstetric ICU. Direct obstetric complications had a better prognosis.

HIV and the Risk of Direct Obstetric Complications: A Systematic Review and Meta-Analysis

BackgroundWomen of reproductive age in parts of sub-Saharan Africa are faced both with high levels of HIV and the threat of dying from the direct complications of pregnancy. Clinicians practicing in such settings have reported a high incidence of direct obstetric complications among HIV-infected women, but the evidence supporting this is unclear. The aim of this systematic review is to establish whether HIV-infected women are at increased risk of direct obstetric complications.Methods and findingsStudies comparing the frequency of obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia and intrauterine infections in HIV-infected and uninfected women were identified. Summary estimates of the odds ratio (OR) for the association between HIV and each obstetric complication were calculated through meta-analyses. In total, 44 studies were included providing 66 data sets; 17 on haemorrhage, 19 on hypertensive disorders, five on dystocia and 25 on intrauterine infections. Meta-analysis of the OR from studies including vaginal deliveries indicated that HIV-infected women had over three times the risk of a puerperal sepsis compared with HIV-uninfected women [pooled OR: 3.43, 95% confidence interval (CI): 2.00–5.85]; this figure increased to nearly six amongst studies only including women who delivered by caesarean (pooled OR: 5.81, 95% CI: 2.42–13.97). For other obstetric complications the evidence was weak and inconsistent.ConclusionsThe higher risk of intrauterine infections in HIV-infected pregnant and postpartum women may require targeted strategies involving the prophylactic use of antibiotics during labour. However, as the huge excess of pregnancy-related mortality in HIV-infected women is unlikely to be due to a higher risk of direct obstetric complications, reducing this mortality will require non obstetric interventions involving access to ART in both pregnant and non-pregnant women.

An Analysis of Pregnancy-Related Mortality in the KEMRI/CDC Health and Demographic Surveillance System in Western Kenya

BackgroundPregnancy-related (PR) deaths are often a result of direct obstetric complications occurring at childbirth.Methods and FindingsTo estimate the burden of and characterize risk factors for PR mortality, we evaluated deaths that occurred between 2003 and 2008 among women of childbearing age (15 to 49 years) using Health and Demographic Surveillance System data in rural western Kenya. WHO ICD definition of PR mortality was used: “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death”. In addition, symptoms and events at the time of death were examined using the WHO verbal autopsy methodology. Deaths were categorized as either (i) directly PR: main cause of death was ascribed as obstetric, or (ii) indirectly PR: main cause of death was non-obstetric. Of 3,223 deaths in women 15 to 49 years, 249 (7.7%) were PR. One-third (34%) of these were due to direct obstetric causes, predominantly postpartum hemorrhage, abortion complications and puerperal sepsis. Two-thirds were indirect; three-quarters were attributable to human immunodeficiency virus (HIV/AIDS), malaria and tuberculosis. Significantly more women who died in lower socio-economic groups sought care from traditional birth attendants (p = 0.034), while less impoverished women were more likely to seek hospital care (p = 0.001). The PR mortality ratio over the six years was 740 (95% CI 651–838) per 100,000 live births, with no evidence of reduction over time (χ2 linear trend = 1.07; p = 0.3).ConclusionsThese data supplement current scanty information on the relationship between infectious diseases and poor maternal outcomes in Africa. They indicate low uptake of maternal health interventions in women dying during pregnancy and postpartum, suggesting improved access to and increased uptake of skilled obstetric care, as well as preventive measures against HIV/AIDS, malaria and tuberculosis among all women of childbearing age may help to reduce pregnancy-related mortality.

A retrospective analysis of maternal and neonatal mortality at a teaching and referral hospital in Kenya

ObjectiveTo measure the incidence of maternal and early neonatal mortality in women who gave birth at Moi Teaching and Referral Hospital (MTRH) in Kenya and describe clinical and other characteristics and circumstances associated with maternal and neonatal deaths following deliveries at MTRH.MethodsA retrospective audit of maternal and neonatal records was conducted with detailed analysis of the most recent 150 maternal deaths and 200 neonatal deaths. Maternal mortality ratios and early neonatal mortality rates were calculated for each year from January 2004 to December 2011.ResultsBetween 2004 and 2011, the overall maternal mortality ratio was 426 per 100,000 live births and the early neonatal mortality rate (<7 days) was 68 per 1000 live births. The Hospital record audit showed that half (51%) of the neonatal mortalities were for young mothers (15–24 years) and 64% of maternal deaths were in women between 25 and 45 years. Most maternal and early neonatal deaths occurred in multiparous women, in referred admissions, when the gestational age was under 37 weeks and in latent stage of labour. Indirect complications accounted for the majority of deaths. Where there were direct obstetric complications associated with the delivery, the leading cause of maternal death was eclampsia and the leading cause of early neonatal death was pre-mature rupture of membranes. Pre-term birth and asphyxia were leading causes of early neonatal deaths. In both sets of records the majority of deliveries were vaginal and performed by midwives.ConclusionThis study provides important information about maternal and early neonatal mortality in Kenya’s second largest tertiary hospital. A range of socio demographic, clinical and health system factors are identified as possible contributors to Kenya’s poor progress towards reducing maternal and early neonatal mortality.

Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited

BackgroundIn Malawi maternal mortality continues to be a major public health challenge. Going beyond the numbers to form a more complete view of why women die is critical to improving access to and quality of emergency obstetric care. The objective of the current study was to identify the socio-cultural and facility-based factors that contributed to maternal deaths in the district of Lilongwe, Malawi.MethodsRetrospectively, 32 maternal death cases that occurred between January 1, 2011 and June 30, 2011 were reviewed independently by two gynecologists/obstetricians. Interviews were conducted with healthcare staff, family members, neighbors, and traditional birth attendants. Guided by the grounded theory approach, interview transcripts were analyzed manually and continuously. Emerging, recurring themes were identified and excerpts from the transcripts were categorized according to the Three Delays Model (3Ds).ResultsSixteen deaths were due to direct obstetric complications, sepsis and hemorrhage being most common. Sixteen deaths were due to indirect causes with the main cause being anemia, followed by HIV and heart disease. Lack of recognizing signs, symptoms, and severity of the situation; using traditional Birth Attendant services; low female literacy level; delayed access to transport; hardship of long distance and physical terrain; delayed prompt quality emergency obstetric care; and delayed care while at the hospital due to patient refusal or concealment were observed. According to the 3Ds, the most common delay observed was in receiving treatment upon reaching the facility due to referral delays, missed diagnoses, lack of blood, lack of drugs, or inadequate care, and severe mismanagement.

O508 THE BURDEN OF DIRECT OBSTETRIC COMPLICATIONS IN NIGERIA

International Journal of Gynecology & ObstetricsVolume 119, Issue S3 p. S441-S441 Free communication (oral) presentations O508 THE BURDEN OF DIRECT OBSTETRIC COMPLICATIONS IN NIGERIA S. Ochejele, S. OchejeleSearch for more papers by this authorP.E. Ogwuche, P.E. OgwucheSearch for more papers by this authorP. Odusolu, P. OdusoluSearch for more papers by this authorA.E. Okwori, A.E. OkworiSearch for more papers by this authorD. Ifenne, D. IfenneSearch for more papers by this authorI.O. Ujah, I.O. UjahSearch for more papers by this author S. Ochejele, S. OchejeleSearch for more papers by this authorP.E. Ogwuche, P.E. OgwucheSearch for more papers by this authorP. Odusolu, P. OdusoluSearch for more papers by this authorA.E. Okwori, A.E. OkworiSearch for more papers by this authorD. Ifenne, D. IfenneSearch for more papers by this authorI.O. Ujah, I.O. UjahSearch for more papers by this author First published: 22 October 2012 https://doi.org/10.1016/S0020-7292(12)60938-2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume119, IssueS3Abstracts of XX FIGO World Congress of Gynecology and ObstetricsOctober 2012Pages S441-S441 RelatedInformation

Community involvement in obstetric emergency management in rural areas: a case of Rukungiri district, Western Uganda.

BackgroundMaternal mortality is a major public health problem worldwide especially in low income countries. Most causes of maternal deaths are due to direct obstetric complications. Maternal mortality ratio remains high in Rukungiri district, western Uganda estimated at 475 per 100,000 live births. The objectives were to identify types of community involvement and examine factors influencing the level of community involvement in the management of obstetric emergencies.MethodsWe conducted a descriptive study during 2nd to 28th February 2009 in rural Rukungiri district, western Uganda. A total of 448 heads of households, randomly selected from 6/11 (54.5%) of sub-counties, 21/42 (50.0%) parishes and 32/212 (15.1%) villages (clusters), were interviewed. Data were analysed using STATA version 10.0.ResultsCommunity pre-emergency support interventions available included community awareness creation (sensitization) while interventions undertaken when emergency had occurred included transportation and referring women to health facility. Community support programmes towards health care (obstetric emergencies) included establishment of community savings and credit schemes, and insurance schemes. The factors associated with community involvement in obstetric emergency management were community members being employed (AOR = 1.91, 95% CI: 1.02 - 3.54) and rating the quality of maternal health care as good (AOR = 2.22, 95% CI: 1.19 - 4.14).ConclusionsTypes of community involvement in obstetric emergency management include practices and support programmes. Community involvement in obstetric emergency management is influenced by employment status and perceived quality of health care services. Policies to promote community networks and resource mobilization strategies for health care should be implemented. There is need for promotion of community support initiatives including health insurance schemes and self help associations; further community sensitization by empowered community based resource persons rather than health workers and improvement in quality of health care can contribute towards effective management of obstetric complications.

User fees and maternity services in Ethiopia

Objectives To examine user fees for maternity services and how they relate to provision, quality, and use of maternity services in Ethiopia. Methods The national assessment of emergency obstetric and newborn care (EmONC) examined user fees for maternity services in 751 health facilities that provided childbirth services in 2008. Results Overall, only about 6.6% of women gave birth in health facilities. Among facilities that provided delivery care, 68% charged a fee in cash or kind for normal delivery. Health centers should be providing maternity services free of charge (the healthcare financing proclamation), yet 65% still charge for some aspect of care, including drugs and supplies. The average cost for normal and cesarean delivery was US $7.70 and US $51.80, respectively. Nineteen percent of these facilities required payment in advance for treatment of an obstetric emergency. The health facilities that charged user fees had, on average, more delivery beds, deliveries (normal and cesarean), direct obstetric complications treated, and a higher ratio of skilled birth attendants per 1000 deliveries than those that did not charge. The case fatality rate was 3.8% and 7.1% in hospitals that did and did not charge user fees, respectively. Conclusion Utilization of maternal health services is extremely low in Ethiopia and, although there is a government decree against charging for maternity service, 65% of health centers do charge for some aspects of maternal care. As health facilities are not reimbursed by the government for the costs of maternity services, this loss of revenue may account for the more and better services offered in facilities that continue to charge user fees. User fees are not the only factor that determines utilization in settings where the coverage of maternity services is extremely low. Additional factors include other out-of-pocket payments such as cost of transport and food and lodging for accompanying relatives. It is important to keep quality of care in mind when user fees are under discussion.