Urban Maternity Unit Research Articles

“It is because the treatment of this lady is a cascade”: Accumulation of delays and the occurrence of obstetric emergencies in an urban maternity unit in Tanzania

ObjectiveTo explore healthcare workers’ and women's experiences of providing and seeking childbirth care in a busy urban maternity facility in Tanzania. DesignA qualitative study with observations, in-depth interviews, and informal conversations, using thematic network analysis. SettingThis study was conducted in a busy urban maternity unit in Dar es Salaam, Tanzania which is a low-resource setting with a need to improve childbirth care. ParticipantsSix frontline healthcare providers and four hospital managers from the facility, along with six postpartum women who gave birth at the facility. FindingsDelays were observed throughout the childbirth care cascade, encompassing various stages. During antenatal care, timely provision of care was hindered by a high patientto-provider ratio, resulting in inadequate monitoring of risk factors. At the onset of labor, women delayed seeking care, sometimes, attempting a trial of labor after a previous Caesarean section. Within the facility, delays in care decision-making and patient management were evident due to insufficient resources. The accumulation of these delays over time influenced the quality of care provided and challenged the management of obstetric emergencies at the study facility. Key conclusionsThe study findings show that delays are prevalent throughout the entire childbirth care cascade. The accumulation of these delays over time has influenced the quality of care provided at the facility and increased the vulnerability of women experiencing obstetric emergencies. To effectively address the imperative of reducing maternal mortality in low-resource settings, it is essential to develop appropriate interventions that span the entire spectrum of childbirth care. Additionally, further research is needed to delve into the complexities of care decision-making and the quality of care delivered within urban maternal facilities. Implications for practiceOur findings stress the need for comprehensive childbirth interventions and contextspecific guidelines to address challenges across the care cascade, particularly in lowresource settings. Urgent attention is required to prioritize care during patient triage and address systemic challenges within the healthcare system to improve birth outcomes and ensure effective facility-based care provision.Trial registration number: NCT04685668Date of initial trial registration: December 28th, 2020

Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study)

ABSTRACT While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants’ perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers’ clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained. Trial registration number: NCT04685668

The change in haemoglobin concentration between the first and third trimesters of pregnancy: a population study

BackgroundThe physiological fall in haemoglobin concentration from the 1st to the 3rd trimester of pregnancy is often quoted as 5 g/L. However, other studies have suggested varying levels of fall between 8 and 13 g/L. We evaluated the change in haemoglobin concentration between the 1st and 3rd trimesters of pregnancy in a multi-ethnic population of pregnant women.MethodsA retrospective cohort analysis of 7054 women with singleton pregnancies, giving birth during 2013–15 in a single urban maternity unit in England.We calculated the changes in haemoglobin concentration from 1st to 3rd trimester using the first trimester haemoglobin as the reference point. The population was stratified into sub-groups to explore any differences that existed within the population.ResultsIn general the fall in haemoglobin concentration was in the order of 14 g/L or 11% of the first trimester value. This fall was consistent for the majority of sub-groups of the population. The fall was lower (7.7%) in the most deprived section of the population, IMD1, but it increased to 11.7% when we restricted that sub-group to pregnant women without health problems during the index pregnancy. Conversely, there was an increase in haemoglobin of 10.2% in women whose first trimester haemoglobin concentration was in the lowest 5% of the total study population. The population fall in haemoglobin was 10.2 g/L (7.8%), after excluding cases above the 95th and below the 5th centiles, and women with a medical and/or obstetric disorder during the pregnancy.ConclusionThe fall in haemoglobin during pregnancy is in the order of 14 g/L or 11% of the first trimester level. This is 2 to 3 times higher than suggested by some guidelines and higher than previously published work. The results challenge the current accepted thresholds for practice, and have broader implications for diagnosis and managment of antenatal anaemia.Tweetable abstractFall in haemoglobin across pregnancy is around 14 g/L (11%) and significantly higher than previously stated in the pregnant population. This poses questions over currently accepted thresholds for anaemia in pregnancy.

An Exploration of the Views and Experiences of Midwives Using Intermittent Auscultation of the Fetal Heart in Labor

OBJECTIVES: To identify the experiences of midwives using intermittent auscultation of the fetal heart rate in labor.DESIGN: A qualitative descriptive study with a sample of 8 midwives, 3 from a DOMINO scheme and 5 from the labor ward at an Irish urban maternity unit. Data collection was through tape-recorded semistructured interviews. Data analysis involved transcription of the interviews verbatim and thematic analysis.FINDINGS: Three core themes were identified: vulnerability, the culture of the organization, and walking the tightrope. The findings suggest that the main challenges which inhibit midwives using intermittent auscultation is the lack of professional guidelines, inconsistency in documentation, and working in a biomedical model of care. The participants also identified that midwives practicing in a midwifery social model of care have more confidence and use midwifery skills to support the use of intermittent auscultation.CONCLUSIONS: The findings suggest working within a midwifery social model of care facilitates the use of intermittent auscultation. Guidelines and education on the explicit use of intermittent auscultation need to be made accessible to midwives. Midwives believed that women could promote the use of intermittent auscultation through their own education on monitoring fetal heart rate options in labor.

Application of objective physical activity measurement in an antenatal physical activity consultation intervention: a randomised controlled trial.

BackgroundPhysical Activity (PA) during pregnancy has many health benefits, however, inactivity in this population is common and PA often declines with increasing gestation. PA consultations have been useful in promoting PA in the general population, however their use for addressing PA in pregnancy is unknown. This study aimed to examine if a theory-based intervention using PA consultations would reduce the magnitude of decline in objectively measured PA between the first and third trimesters of pregnancy.MethodsA RCT was carried out in an urban maternity unit in Northern Ireland between September 2012 and June 2013. 109 low-risk, primigravida pregnant women were randomised to a control (n = 54) or intervention group (n = 55). Intervention participants received three face-to-face individual PA consultations. Daily PA was measured in each trimester using seven day accelerometry. The study was approved by a NHS trust (12/NI/0036). PA data in counts per minute (CPM) were categorised into intensity using Freedson cut points and mean minutes of PA were compared between groups using repeated measures ANOVA with a sub-analysis stratifying participants per PA level in trimester one.ResultsIntention to treat analysis was performed on data from 97 participants. Time in moderate, vigorous and moderate-vigorous intensity PA (MVPA) significantly declined between trimesters one and three in both groups (P < 0.001). There were no statistically significant differences in PA between groups in any trimester. Women in the intervention group who were less active in trimester one did not demonstrate a significant decline in MVPA throughout pregnancy (in contrast with the decline identified in the more active participants).ConclusionsThe findings indicate that PA consultations were not effective in reducing the decline of MVPA in throughout pregnancy, however, women who were less active in trimester one and received PA consultations had a lesser decrease in MVPA. It is possible that pregnant women, specifically those who are more active at the start of pregnancy, have differing needs for PA behaviour change and maintenance, requiring more intense interventions than less active women.Trial RegistrationCurrent Controlled Trials Register ISRCTN61829137.

Serious gaming for neonatal resucitation skills maintainance

During the first moments after birth, neonates undergo dramatic physiological changes to successfully adapt to the extra uterine environment the most important of which is establishment of independent respiration. Although other newborn body systems change their level of functioning gradually, radical and rapid cardiopulmonary adaptation must occur for neonates to survive. For some, the physiological challenge is great. It is estimated that approximately 10% of all newborns require some assistance to begin breathing and less than 1% require extensive resuscitation 3. Live births in the United Kingdom in 2011 were 797,778 therefore around 79,700 babies require assistance each year in the UK to establish independent respiration. Although early neonatal depression is common, it may not be always predicted prior to birth. The need for resuscitation may only be anticipated in around 50% of cases therefore, the presence of personnel adequately prepared to perform resuscitation is an important first step in newborn resuscitation. A rapid, knowledgeable, and skilful response by all caregivers is essential. However, there can be significant variation in the presence of skilled personnel at newborn resuscitation. Maternity Care professionals who have attended simulation training have demonstrated that they retain knowledge, but alarming loss 8 of skill performance occurs by 6 months after training for resuscitation. This situation is exacerbated when professionals have relatively few opportunities to use their skills. Midwives and Doctors in large urban maternity units usually perform resuscitations on a regular basis, which reinforces their knowledge and skills gained during participation in simulation training. Professionals providing care in rural hospitals usually practise as generalists and are challenged in maintaining their resuscitation skills because the number of births to which they attend is small. Scottish remote and rural maternity service teams face increasing challenges in maintaining a broad range of skills in the context of isolated clinical practice and a dispersed patient population. Skills may not be honed when the unexpected need to use them occurs. Incomplete or erroneous knowledge, skills that are out of practice and lack of confidence or belief in the effectiveness of an intervention may all contribute to delayed initiation of resuscitation or ineffective performance. National clinical skills training through the SMMDP exists to support such teams but ways of extending the effective lifespan of training and maintaining skills were sought by SMMDP. There is increasing evidence that serious games that are designed to solve a problem may be of use to today’s practitioners. It has been demonstrated that video game skill correlates with International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116505– http://www.ijic.org/ laparoscopic surgical skills. Training programmes that include video games may help in the technical interface between surgeons and screen-mediated applications, such as laparoscopic surgery. There are many advantages to using simulated or computer based environments, including: they present no risk to human patients, they provide structured learning opportunities with defined learning objectives. They enable practice without interruption or interference and can be scheduled at times convenient to users. They also facilitate practice of routine and rare situations and foster integration of cognitive, technical and behavioural skills. The SMMDP has developed a neonatal serious game with a number of resucitation scenarios and is exploring the world of computer games and mobile apps in the light of the considerable body of evidence to prove that regular play has a beneficial impact on spatial awareness and coordination. Playing this game on PC, and on ipads and mobile phones, may be practical teaching tools to help maternity care professionals maintain their skills.

A Randomized Controlled Trial of Routine Versus Restrictive Use of Episiotomy at Operative Vaginal Delivery: A Multicentre Pilot Study

The use of episiotomy as a routine component of operative vaginal delivery (OVD) is decreasing. Although a majority of physicians believe that routine use of episiotomy at OVD is protective against anal sphincter tears, the evidence on this issue is conflicting. A recent large retrospective Dutch study reported that episiotomy was highly protective against anal sphincter tears. This randomized controlled pilot study compared the maternal and neonatal outcomes of routine versus restrictive use of episiotomy at OVD in 200 nulliparous women expected to deliver at ≥37 weeks of gestation with live singleton cephalic pregnancies. The women were recruited in the antenatal period at 2 urban maternity units in Scotland and England between 2004 and 2006. Of the 200 study subjects, 99 were randomized to routine use of episiotomy (in all cases) and 101 to restrictive use of episiotomy (only if tearing becomes apparent). Anal sphincter tearing (third or fourth degree) was the primary outcome. Compared with restrictive use of episiotomy, routine use was associated with only a small and statistically insignificant difference in the rate of anal sphincter tears (8.1% routine vs. 10.9% restrictive); the odds ratio (OR) was 0.72, with a 95% confidence interval (CI) of 0.28 to 1.87. Routine use of episiotomy was associated with a slight but statistically insignificant increase in the incidence of both primary postpartum hemorrhage: 36.4% routine vs. 26.7% restrictive, with an OR of 1.57 and a 95% CI of 0.86 to 2.86, and neonatal trauma: 45.5% routine versus 43.6% restrictive, with an OR 1.08 and a 95% CI of 0.62 to 1.89. There were also no statistically meaningful differences between the 2 groups in prolonged postnatal stay, prolonged catheterization, urinary or fecal incontinence, perineal infection, rates of shoulder dystocia, or pain requiring moderate or strong analgesia. The findings of this small pilot study provide no evidence to support a policy of either routine or restrictive use of episiotomy at OVD and suggest the need for a large randomized controlled trial.

A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study

To compare the maternal and neonatal outcomes of operative vaginal delivery in relation to the use of episiotomy. Pilot randomised controlled trial (RCT). Two urban maternity units in Scotland and England. Nulliparous women anticipating a singleton cephalic vaginal delivery were recruited in the antenatal period. If an operative vaginal delivery was required in the second stage of labour, women were randomised to either routine (in all cases) or restrictive (only if tearing apparent) use of episiotomy. The primary outcome was anal sphincter tearing (third or fourth degree). Secondary outcomes included postpartum haemorrhage (PPH), neonatal trauma and pelvic floor symptoms up until 10 days postpartum. In a group of 317 women requiring operative vaginal delivery, 200 were randomised: 99 to routine use of episiotomy and 101 to restrictive use. There were small differences in the rates of anal sphincter tears (8.1% routine versus 10.9% restrictive, OR 0.72, 95% CI 0.28-1.87) and primary PPH (36.4% routine versus 26.7% restrictive, OR 1.57, 95% CI 0.86-2.86). Neonatal trauma was similar between the two groups (45.5% routine versus 43.6% restrictive, OR 1.08, 95% CI 0.62-1.89), as was prolonged catheterisation, urinary incontinence, faecal incontinence, perineal infection and prolonged hospital admission. This pilot study does not provide conclusive evidence that a policy of routine episiotomy is better or worse than a restrictive policy. A definitive RCT is feasible but will require a large sample size to inform clinical practice.

A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery

To evaluate the maternal and neonatal morbidity of operative vaginal delivery in relation to the use of episiotomy. Prospective cohort study. Two urban maternity units in Scotland and England. All nonrandomised nulliparous women delivered by forceps or vacuum during the recruitment period of a clinical trial evaluating the use of episiotomy at operative vaginal delivery. Use of episiotomy was compared to no episiotomy for all operative vaginal deliveries with sub-group analyses for forceps or vacuum deliveries. The primary outcome was anal sphincter tearing (third or fourth degree). Secondary outcomes included postpartum haemorrhage, neonatal trauma and pelvic floor symptoms up until 10 days postpartum. A total of 1360 women were included in the study, of whom 294 (21.6%) did not receive an episiotomy. Vacuum delivery was associated with less use of episiotomy than forceps (56.1 versus 89.4%, OR 0.15, 95% CI 0.11-0.20). Anal sphincter tear rates were not statistically different with use of episiotomy compared with no episiotomy (9.9 versus 7.1%, adjusted OR 1.11, 95% CI 0.66-1.87). Episiotomy use was associated with higher rates of postpartum haemorrhage (28.5 versus 18.4%, adjusted OR 1.72, 95% CI 1.21-2.45), need for moderate or strong analgesia (90.5 versus 67.6%, adjusted OR 3.70, 95% CI 2.60-5.27), perineal infection (5.1 versus 1.4%, adjusted OR 4.04, 95% CI 1.44-11.37) and neonatal trauma (38.1 versus 22.0%, adjusted OR 1.65, 95% CI 1.20-2.27). Use of episiotomy did not reduce the risk of shoulder dystocia (3.5 versus 1.7%, adjusted OR 1.42, 95% CI 0.53-3.85). The use of episiotomy did not reduce or greatly increase anal sphincter tears and was associated with greater maternal and neonatal morbidity. This may reflect the complexity of deliveries. The role of episiotomy at operative vaginal delivery should be evaluated in a randomised controlled trial.

Midwives' competence: is it affected by working in a rural location?

Rising health care costs and the need to consolidate expertise in tertiary services have led to the centralisation of services. In the UK, the result has been that many rural maternity units have become midwife-led. A key consideration is that midwives have the skills to competently and confidently provide maternity services in rural areas, which may be geographically isolated and where the midwife may only see a small number of pregnant women each year. Our objective was to compare the views of midwives in rural and urban settings, regarding their competence and confidence with respect to 'competencies' identified as being those which all professionals should have in order to provide effective and safe care for low-risk women. This was a comparative questionnaire survey involving a stratified sample of remote and rural maternity units and an ad hoc comparison group of three urban maternity units in Scotland. Questionnaires were sent to 82 midwives working in remote and rural areas and 107 midwives working in urban hospitals with midwife-led units. The response rate from midwives in rural settings was considerably higher (85%) than from midwives in the urban areas (60%). Although the proportion of midwives who reported that they were competent was broadly similar in the two groups, there were some significant differences regarding specific competencies. Midwives in the rural group were more likely to report competence for breech delivery (p = 0.001), while more urban midwives reported competence in skills such as intravenous fluid replacement (p <0.001) and initial and discharge examination of the newborn (p <0.001). Both groups reported facing barriers to continuing professional development; however, more of the rural group had attended an educational event within the last month (p <0.001). Lack of time was a greater barrier for urban midwives (p = 0.02), whereas distance to training was greater for rural midwives (p = 0.009). Lack of motivation or interest was significantly higher in urban units (p = 0.006). It is often assumed that midwives in rural areas where there are fewer deliveries, will be less competent and confident in their practice. Our exploratory study suggests that the issue of competence is far more complex and deserves further attention.

Glucose tolerance in pregnancy in South India: relationships to neonatal anthropometry

The incidence of type 2 diabetes is increasing worldwide, most rapidly in developing countries such as India. Exposure as a fetus to maternal gestational diabetes is thought to be a risk factor for developing the disease. This study was set up to determine the incidence of gestational diabetes mellitus in one urban maternity unit in South India and to examine its effect on the offspring's neonatal anthropometry, childhood growth, and glucose/insulin metabolism. This paper reports neonatal outcomes. Seven hundred and eighty five women were recruited consecutively from the antenatal clinic of the Holdsworth Memorial Hospital, Mysore and underwent a 100 g, 3-hr oral glucose tolerance test at 30 +/- 2 weeks gestation. Gestational diabetes was defined using Carpenter and Coustan criteria. The babies were measured in detail at birth. Mean maternal age and body mass index were 23.6 years and 23.1 kg/m(2). The incidence of gestational diabetes was 6.2%. Mothers with gestational diabetes had babies that were heavier (3339 g compared with 2956 g for non-diabetic mothers) and larger in measurements of fat, muscle, and skeleton. Even in non-diabetic pregnancies, neonatal weight, head circumference, and ponderal index were positively related to maternal fasting glucose concentrations (P < or = 0.05 for all). The incidence of gestational diabetes was high in this unselected sample of mothers booking into one urban Indian maternity unit. Community-based studies are required to confirm this. The effect of maternal glucose concentrations on neonatal anthropometry is continuous and extends into the "normal" glycemic range.

A survey of exercise patterns in primigravidae at a Scottish NHS Trust: More consistent support and advice required for women and their families

Objective To examine primigravidae women's reported exercise patterns, approaches to exercise and information sources on exercise. Design Face-to-face survey. Setting Urban maternity unit in a Scottish city centre hospital. Method Survey of 42 consecutive recently-delivered primigravidae. Results The women exercised less as they got older and this reduction was exacerbated as pregnancy advanced, particularly for vigorous activities. Exercise declined significantly during the first trimester, a period during which 37 per cent of the women believed that exercise increased the risk of miscarriage. Over the trimesters of pregnancy a significant minority of women (40 per cent) received no advice from any sources on exercise during pregnancy. For the remainder, a wide range of different information sources on exercise were drawn upon, including health professionals, family and educational literature. All women knew that exercise had physical benefits for themselves and their babies but only a minority cited cardiovascular benefits specifically; while 34 per cent of respondents believed that exercise in later pregnancy could be beneficial to the baby. Women from poorer social backgrounds received significantly less advice at all stages of pregnancy ( p&lt; 0.01). Conclusion Pregnancy is a period during which women's perception of risk is likely to be heightened, exercise patterns change and physical activity lessens. Women in this study either tended to receive no advice on exercise during pregnancy or received information from a wider variety of professional and lay sources. Health professionals should therefore promote the benefits of exercise to both pregnant women and their families throughout the trimesters of pregnancy. Support should be particularly targeted to those from lower socioeconomic groups.

The Childbirth Self-Efficacy Inventory: a replication study.

In 1993 Lowe developed the Childbirth Self-Efficacy Inventory (CBSEI). This is a self-administered, 62-item, Likert tool which measures women's confidence in their ability to cope with labour. The tool is valid and reliable for use in American culture but had not been tested in Northern Ireland, therefore a replication study was deemed necessary. The research study set out to replicate Lowe's study and to test the potential application of this tool in clinical midwifery practice. A convenience sample comprising a cohort of 126 women attending an urban maternity unit in Northern Ireland formed the study population and a response rate of 64% was achieved. The tool was administered antenatally, intranatally and postnatally. The predictive validity of the instrument was tested to determine actual coping behaviours in labour (Pearson's r=0.3963, P < 0.00 for active labour; r=0.5149, P < 0.00 for second stage labour). This work confirms the CBSEI as a measurement of confidence in women's ability to cope in labour. The authors recommend the utility of the CBSEI in midwifery practice as a tool for the identification of women who will require extra support in labour and pregnancy.

Midwives' experience of stress on the labour ward

The word stress is used to describe both mental and physical conditions that may be beneficial and harmful in its sources and effects. The objectives of this study were to measure stress levels as perceived by midwives working on the labour ward, to identify both personal and professional sources of stress for midwives, to examine the perceived effects of stress on midwives, to identify stress relieving methods used by midwives, and to identify the sources of support for midwives in labour wards. This research utilized the McGrath et al (1989) and the GHQ-12 (Goldberg, 1978) self report questionnaires to measure labour ward midwives' stress in a large urban maternity unit. Results from the study highlighted the stressful effects of poor communication between doctors and midwives.

Obstetric transfers and maternal mortality: a study in Conakry, Guinea

A retrospective study was made of 349 obstetric patients transferred from suburban maternity units to 2 referral maternity units in the capital city of Conakry Guinea from July 1 1989 to June 30 1990 in order to determine the influence of such a transfer on maternal mortality. Data collected from medical reports and transfer registries included sociodemographic data reproductive history time of transfer original diagnosis diagnosis at admission outcome and place of delivery and cause of death if applicable. The women had a mean age of 24 years. 96% were married or living as a couple 25% were engaged in a profession and 35% had less than 5 years schooling. Mean parity was 2.0; 40% were primigravida 27% had had 5 or more pregnancies and 11% had previous obstetric complications including 6% who had a previous Cesarean section. 161 of the women had a Cesarean section for this birth and 18 of these died. A total of 25 of the women died of infection (28%) ruptured uterus (12%) postpartum hemorrhage (19%) and hypertensive disorders (16%). Since there were 123 maternal deaths in Conakrys maternity units and suburban hospitals during this period 20% of the women who died had been transferred. There were no seasonal variations in the average of 27 women who were transferred each month (3% of the total deliveries). Reasons for the transfers were not given for 20% of the women but a third were transferred for nonprogression of labor and many were transferred for rupture of the uterus. An additional 60 women were transferred but were not usually resident in Conakry and were thus not included in the above analysis. Of these 5 had complications of abortion and 30 a previous Cesarean section. 11 of these women died. The rate of mortality due to ruptured uterus was high considering the short distance between the urban maternity units and the referral units and was most likely caused by the absence of both a partograph and a defined obstetric decision tree which delayed the transfer of women with real complications. The high death rate and the difference between original and admission diagnoses point to an urgent need for staff training in early detection of dystocial deliveries especially through the introduction and use of the partograph.