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Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study.

ABSTRACT: To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital.A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ?2000 g (n?=?139), compared to controls with birthweight ?2000 g and Apgar score ?7 (n?=?249).The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital's registers. The majority of singletons had birthweight ?2000 g (n?=?139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75-315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06-3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68-5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70-12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect.Intrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities.This is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).

SUBMITTER: Maaloe N

PROVIDER: S-EPMC5103376 | biostudies-literature | 2016 Nov

REPOSITORIES: biostudies-literature

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Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study.

Maaløe Nanna N Housseine Natasha N Bygbjerg Ib Christian IC Meguid Tarek T Khamis Rashid Saleh RS Mohamed Ali Gharib AG Nielsen Birgitte Bruun BB van Roosmalen Jos J

BMC pregnancy and childbirth 20161110 1

<h4>Background</h4>To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital.<h4>Methods</h4>A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249).<h4>Results</h4>The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital's ...[more]

PMID: 27832753

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Project description:Poor intra-facility maternity care is a major contributor to maternal mortality in low- and middle-income countries. Close to 830 women die each day due to preventable maternal complications, partly due to the increasing number of women giving birth in health facilities that are not adequately resourced to manage growing patient populations. Barriers to adequate care during the 'last mile' of healthcare delivery are attributable to deficiencies at multiple levels: education, staff, medication, facilities, and delays in receiving care. Moreover, the scope and multi-scale interdependence of these factors make individual contributions of each challenging to analyze, particularly in settings where basic data registration is often lacking. To address this need, we have designed and implemented a novel systems-level and dynamic mathematical model that simulates the impact of hospital resource allocations on maternal mortality rates at Mnazi Mmoja Hospital (MMH), a referral hospital in Zanzibar, Tanzania. The purpose of this model is to provide a rigorous and flexible tool that enables hospital administrators and public health officials to quantitatively analyze the impact of resource constraints on patient outcomes within the maternity ward, and prioritize key areas for further human or capital investment. Currently, no such tool exists to assist administrators and policy makers with effective resource allocation and planning. This paper describes the structure and construct of the model, provides validation of the assumptions made with anonymized patient data and discusses the predictive capacity of our model. Application of the model to specific resource allocations, maternal treatment plans, and hospital loads at MMH indicates through quantitative results that medicine stocking schedules and staff allocations are key areas that can be addressed to reduce mortality by up to 5-fold. With data-driven evidence provided by the model, hospital staff, administration, and the local ministries of health can enact policy changes and implement targeted interventions to improve maternal health outcomes at MMH. While our model is able to determine specific gaps in resources and health care delivery specifically at MMH, the model should be viewed as an additional tool that may be used by other facilities seeking to analyze and improve maternal health outcomes in resource constrained environments.

Project description:BackgroundApproximately one million stillbirths occur annually during labour; most of these stillbirths occur in low and middle-income countries and are associated with absent, inadequate, or delayed obstetric care. The low proportion of intrapartum stillbirths in high-income countries suggests that intrapartum stillbirths are largely preventable with quality intrapartum care, including prompt recognition and management of intrapartum complications. The evidence for impact of intrapartum interventions on stillbirth and perinatal mortality outcomes has not yet been systematically examined.MethodsWe undertook a systematic review of the published literature, searching PubMed and the Cochrane Library, of trials and reviews (N = 230) that reported stillbirth or perinatal mortality outcomes for eight interventions delivered during labour. Where eligible randomised controlled trials had been published after the most recent Cochrane review on any given intervention, we incorporated these new trial findings into a new meta-analysis with the Cochrane included studies.ResultsWe found a paucity of studies reporting statistically significant evidence of impact on perinatal mortality, especially on stillbirths. Available evidence suggests that operative delivery, especially Caesarean section, contributes to decreased stillbirth rates. Induction of labour rather than expectant management in post-term pregnancies showed strong evidence of impact, though there was not enough evidence to suggest superior safety for the fetus of any given drug or drugs for induction of labour. Planned Caesarean section for term breech presentation has been shown in a large randomised trial to reduce stillbirths, but the feasibility and consequences of implementing this intervention routinely in low-/middle-income countries add caveats to recommending its use. Magnesium sulphate for pre-eclampsia and eclampsia is effective in preventing eclamptic seizures, but studies have not demonstrated impact on perinatal mortality. There was limited evidence of impact for maternal hyperoxygenation, and concerns remain about maternal safety. Transcervical amnioinfusion for meconium staining appears promising for low/middle income-country application according to the findings of many small studies, but a large randomised trial of the intervention had no significant impact on perinatal mortality, suggesting that further studies are needed.ConclusionAlthough the global appeal to prioritise access to emergency obstetric care, especially vacuum extraction and Caesarean section, rests largely on observational and population-based data, these interventions are clearly life-saving in many cases of fetal compromise. Safe, comprehensive essential and emergency obstetric care is particularly needed, and can make the greatest impact on stillbirth rates, in low-resource settings. Other advanced interventions such as amnioinfusion and hyperoxygenation may reduce perinatal mortality, but concerns about safety and effectiveness require further study before they can be routinely included in programs.

Project description:BackgroundThe majority of the world's perinatal deaths occur in low- and middle-income countries. A substantial proportion occurs intrapartum and is avoidable with better care. At a low-resource tertiary hospital, this study assessed the quality of intrapartum care and adherence to locally-tailored clinical guidelines.MethodsA non-participatory, structured, direct observation study was held at Mnazi Mmoja Hospital, Zanzibar, Tanzania, between October and November 2016. Women in active labour were followed and structure, processes of labour care and outcomes of care systematically recorded. Descriptive analyses were performed on the labour observations and compared to local guidelines and supplemented by qualitative findings. A Poisson regression analysis assessed factors affecting foetal heart rate monitoring (FHRM) guidelines adherence.Results161 labouring women were observed. The nurse/midwife-to-labouring-women ratio of 1:4, resulted in doctors providing a significant part of intrapartum monitoring. Care during labour and two-thirds of deliveries was provided in a one-room labour ward with shared beds. Screening for privacy and communication of examination findings were done in 50 and 34%, respectively. For the majority, there was delayed recognition of labour progress and insufficient support in second stage of labour. While FHRM was generally performed suboptimally with a median interval of 105 (interquartile range 57-160) minutes, occurrence of an intrapartum risk event (non-reassuring FHR, oxytocin use or poor progress) increased assessment frequency significantly (rate ratio 1.32 (CI 1.09-1.58)).ConclusionsNeither international nor locally-adapted standards of intrapartum routine care were optimally achieved. This was most likely due to a grossly inadequate capacity of birth attendants; without whom innovative interventions at birth are unlikely to succeed. This calls for international and local stakeholders to address the root causes of unsafe intrafacility care in low-resource settings, including the number of skilled birth attendants required for safe and respectful births.

Project description:BackgroundScreening and monitoring in pregnancy are strategies used by healthcare providers to identify high-risk pregnancies so that they can provide more targeted and appropriate treatment and follow-up care, and to monitor fetal well-being in both low- and high-risk pregnancies. The use of many of these techniques is controversial and their ability to detect fetal compromise often unknown. Theoretically, appropriate management of maternal and fetal risk factors and complications that are detected in pregnancy and labour could prevent a large proportion of the world's 3.2 million estimated annual stillbirths, as well as minimise maternal and neonatal morbidity and mortality.MethodsThe fourth in a series of papers assessing the evidence base for prevention of stillbirths, this paper reviews available published evidence for the impact of 14 screening and monitoring interventions in pregnancy on stillbirth, including identification and management of high-risk pregnancies, advanced monitoring techniques, and monitoring of labour. Using broad and specific strategies to search PubMed and the Cochrane Library, we identified 221 relevant reviews and studies testing screening and monitoring interventions during the antenatal and intrapartum periods and reporting stillbirth or perinatal mortality as an outcome.ResultsWe found a dearth of rigorous evidence of direct impact of any of these screening procedures and interventions on stillbirth incidence. Observational studies testing some interventions, including fetal movement monitoring and Doppler monitoring, showed some evidence of impact on stillbirths in selected high-risk populations, but require larger rigourous trials to confirm impact. Other interventions, such as amniotic fluid assessment for oligohydramnios, appear predictive of stillbirth risk, but studies are lacking which assess the impact on perinatal mortality of subsequent intervention based on test findings. Few rigorous studies of cardiotocography have reported stillbirth outcomes, but steep declines in stillbirth rates have been observed in high-income settings such as the U.S., where cardiotocography is used in conjunction with Caesarean section for fetal distress.ConclusionThere are numerous research gaps and large, adequately controlled trials are still needed for most of the interventions we considered. The impact of monitoring interventions on stillbirth relies on use of effective and timely intervention should problems be detected. Numerous studies indicated that positive tests were associated with increased perinatal mortality, but while some tests had good sensitivity in detecting distress, false-positive rates were high for most tests, and questions remain about optimal timing, frequency, and implications of testing. Few studies included assessments of impact of subsequent intervention needed before recommending particular monitoring strategies as a means to decrease stillbirth incidence. In high-income countries such as the US, observational evidence suggests that widespread use of cardiotocography with Caesarean section for fetal distress has led to significant declines in stillbirth rates. Efforts to increase availability of Caesarean section in low-/middle-income countries should be coupled with intrapartum monitoring technologies where resources and provider skills permit.

Project description:BackgroundDiabetic nephropathy is the most serious complication of diabetes which leads to end-stage renal failure and other complication of diabetes mellitus. Determinants of Diabetic nephropathy are not consistent in different studies and associated factors to chronic complications of diabetes are not specific and there are limited studies specific to diabetic nephropathy. Thus, the aim of this study is to identify determinants of diabetic nephropathy in Ayder Referral Hospital, Northern Ethiopia.MethodsA case-control study was conducted from February 14 to May 8 2016. Diabetic patients who developed nephropathy in the last two years were the cases and diabetic patients free of nephropathy were controls. Cases and controls were identified detailed review of the chronic care follow up chart. Then simple random sampling was used to select sample of 420 (with control to case ratio of 4:1) resulting in 84 cases and 336 controls. Record review and interviewer administered questionnaire were used to collect data. Data was coded and entered in to Epi-Data version 3.1 and then exported to STATA 12 for analysis. Variables with P-values< 0.25 in Bivariate logistic regression were selected for multiple logistic regressions to determine independent determinants of diabetic nephropathy. OR was calculated with 95% CI to show strength of association.ResultThe mean age (±Standard deviation) for the cases and the controls were 52(SD: ±1.34) and 42.4(SD: ±0.8) respectively. In multiple logistic regressions age of patient (AOR: 1.037 95%CI: 1.01-1.064), duration of diabetes after diagnosis (AOR for one year increase: 1.09 95%CI: 1.036-1.15), not-adhered to blood glucose measurement at home (AOR: 6.81 95%CI: 1.15-40.24), having Systolic Hypertension (AOR;2.13 (1.002-4.51), poor glycemic control (AOR;2.71 95%CI: (1.49-4.95), being overweight(AOR;2.7(1.47-4.96) were the independent predictors of diabetic nephropathy.ConclusionIn the light of these findings, targeted interventions should be designed at the follow up clinic to address the risk of developing diabetic nephropathy among the risk groups.

Project description:While international guidelines for intrapartum care appear to have increased rapidly since 2000, literature suggests that it has only in few instances been matched with reviews of local modifications, use, and impact at the targeted low resource facilities. At a Tanzanian referral hospital, this paper describes the development process of locally achievable, partograph-associated, and peer-reviewed labour management guidelines, and it presents an assessment of professional birth attendants' perceptions.Part 1: Modification of evidence-based international guidelines through repeated evaluation cycles by local staff and seven external specialists in midwifery/obstetrics. Part 2: Questionnaire evaluation 12 months post-implementation of perceptions and use among professional birth attendants.Part 1: After the development process, including three rounds of evaluation by staff and two external peer-review cycles, there were no major concerns with the guidelines internally nor externally. Thereby, international recommendations were condensed to the eight-paged 'PartoMa guidelines ©'. This pocket booklet includes routine assessments, supportive care, and management of common abnormalities in foetal heart rate, labour progress, and maternal condition. It uses colour codes indicating urgency. Compared to international guidelines, reductions were made in frequency of assessments, information load, and ambiguity. Part 2: Response rate of 84% (n = 84). The majority of staff (93%) agreed that the guidelines helped to improve care. They found the guidelines achievable (89%), and the graphics worked well (90%). Doctors more often than nurse-midwives (89% versus 74%) responded to use the guidelines daily.The PartoMa guidelines ensure readily available, locally achievable, and acceptable support for intrapartum surveillance, triage, and management. This is a crucial example of adapting evidence-based international recommendations to local reality.This paper describes the intervention of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).

Project description:BackgroundThis study compared TB diagnostic tools and estimated levels of misdiagnosis in a resource-limited setting. Furthermore, we estimated the diagnostic utility of three-TB-associated predictors in an algorithm with and without Direct Ziehl-Neelsen (DZM).Materials and methodsData was obtained from a cross-sectional study in 2011 conducted at Mubende regional referral hospital in Uganda. An individual was included if they presented with a two weeks persistent cough and or lymphadenitis/abscess. 344 samples were analyzed on DZM in Mubende and compared to duplicates analyzed on direct fluorescent microscopy (DFM), growth on solid and liquid media at Makerere University. Clinical variables from a questionnaire and DZM were used to predict TB status in multivariable logistic and Cox proportional hazard models, while optimization and visualization was done with receiver operating characteristics curve and algorithm-charts in Stata, R and Lucid-Charts respectively.ResultsDZM had a sensitivity and specificity of 36.4% (95% CI = 24.9-49.1) and 97.1%(95% CI = 94.4-98.7) compared to DFM which had a sensitivity and specificity of 80.3%(95% CI = 68.7-89.1) and 97.1%(95% CI = 94.4-98.7) respectively. DZM false negative results were associated with patient's HIV status, tobacco smoking and extra-pulmonary tuberculosis. One of the false negative cases was infected with multi drug resistant TB (MDR). The three-predictor screening algorithm with and without DZM classified 50% and 33% of the true cases respectively, while the adjusted algorithm with DZM classified 78% of the true cases.ConclusionThe study supports the concern that using DZM alone risks missing majority of TB cases, in this case we found nearly 60%, of who one was an MDR case. Although adopting DFM would reduce this proportion to 19%, the use of a three-predictor screening algorithm together with DZM was almost as good as DFM alone. It's utility is whoever subject to HIV screening all TB suspects.

Project description:BackgroundLabour dystocia (LD) is associated with maternal and foeto-neonatal complications and increased rate of caesarean section. There are scant studies on predictive factors of labour dystocia in Iran, as well as in other countries. Therefore, this study aimed to identify the predictive factors of LD using an integrated and collaborative pre- and during- labour factors to help formulate more effective intervention strategies for prevention and management of LD.MethodsIn this case-control study, 350 women with and 350 women without LD, matched individually in terms of parity and hospital, were compared. The participants were in active labor, had singleton pregnancy, live foetus with a cephalic presentation, gestational age of 37+ 0-41+ 6 weeks, and were hospitalized for vaginal birth in two teaching hospitals in Tabriz, Iran. Data related to the socio-demographic characteristics, anxiety status (using the Spielberger State Anxiety Inventory), and woman dehydration were collected at cervical dilatation between 4 and 6 cm (before dystocia detection) and the other data at different phases of labour, and after birth (before discharge). The multivariate logistic regression was used to determine the predictors.ResultsThe predictors of LD were severe [OR 58.0 (95% CI 26.9 to 125.1)] and moderate [8.6 (4.2 to 17.4)] anxiety, woman dehydration > 3 h [18.67 (4.0 to 87.3)] and ≤ 3 h [2.8 (1.7 to 4.8], insufficient support by the medical staff in the delivery room [5.8 (1.9 to 17.9)], remifentanil administration [3.1 (1.5 to 6.2)], labour induction [4.2 (2.5 to 7.2], low income [2.0 (1.2 to 3.3)], woman's height < 160 cm [2.0 (1.1 to 3.3)], and woman age of 16-20 y [0.3 (0.2 to 0.6)]. The proportion of the variance explained by all these factors was 74%.ConclusionThe controllable predictors, such as woman anxiety and dehydration, and insufficient support from medical staff during labour were strongly associated with the risk of LD. Therefore, it seems that responding to woman physical, psychological, and supportive needs during labour can play a significant role in LD prevention and control.Ethical codeIR.TBZMED.REC.1397.624.

Dataset Information

Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study.

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Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study.

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