Clinical algorithms for management of third stage abnormalities.

AIMS: To develop algorithms for identifying, managing and monitoring postpartum haemorrhage (PPH) and other third stage of labour abnormalities after vaginal delivery. POPULATION: Women with low-risk singleton term pregnancies who have had a vaginal delivery. SETTING: Hospital settings with a particular focus on healthcare facilities in low- and middle-income countries (LMICs). SEARCH STRATEGY: Searches for international and national guidance documents, research databases (Cochrane, Medline and CINAHL) and published systematic reviews. Searches were limited to work published in English between 1 January 2008 and 31 December 2018. CASE SCENARIOS: Four interlinked case scenarios were identified for algorithm development: (1) an approach to PPH after vaginal delivery, (2) uterine atony, (3) genital tract trauma and (4) retained placenta/placental products. CONCLUSIONS: The development of clear approaches to the assessment, resuscitation, treatment and monitoring of the four case scenarios are presented as algorithms, based on available evidence. They need to be field tested and evaluated for effectiveness, and may be adapted for electronic decision support tools using artificial intelligence in different settings. Further research is needed around multimodal sequential packages of care for PPH, conservative surgical measures, resuscitation in LMICs, and how a respectful maternity care focus can be incorporated into the algorithms. TWEETABLE ABSTRACT: Algorithm development for standardised approaches to managing PPH in low-resource settings.

Constructing evidence-based clinical intrapartum care algorithms for decision-support tools.

AIM: To describe standardised iterative methods used by a multidisciplinary group to develop evidence-based clinical intrapartum care algorithms for the management of uneventful and complicated labours. POPULATION: Singleton, term pregnancies considered to be at low risk of developing complications at admission to the birthing facility. SETTING: Health facilities in low- and middle-income countries. SEARCH STRATEGY: Literature reviews were conducted to identify standardised methods for algorithm development and examples from other fields, and evidence and guidelines for intrapartum care. Searches for different algorithm topics were last updated between January and October 2020 and included a combination of terms such as 'labour', 'intrapartum', 'algorithms' and specific topic terms, using Cochrane Library and MEDLINE/PubMED, CINAHL, National Guidelines Clearinghouse and Google. CASE SCENARIOS: Nine algorithm topics were identified for monitoring and management of uncomplicated labour and childbirth, identification and management of abnormalities of fetal heart rate, liquor, uterine contractions, labour progress, maternal pulse and blood pressure, temperature, urine and complicated third stage of labour. Each topic included between two and four case scenarios covering most common deviations, severity of related complications or critical clinical outcomes. CONCLUSIONS: Intrapartum care algorithms provide a framework for monitoring women, and identifying and managing complications during labour and childbirth. These algorithms will support implementation of WHO recommendations and facilitate the development by stakeholders of evidence-based, up to date, paper-based or digital reminders and decision-support tools. The algorithms need to be field tested and may need to be adapted to specific contexts. TWEETABLE ABSTRACT: Evidence-based intrapartum care clinical algorithms for a safe and positive childbirth experience.

The Confidential Enquiry into Maternal Deaths in South Africa: a case study.

The Confidential Enquiry into Maternal Deaths (CEMD) in South Africa has been operational for 15 years. This case study describes the process of notification and independent assessment of maternal deaths, predominantly in facilities. In the earlier years of the Enquiry, institutional maternal mortality ratio increased and was 176.2 per 100 000 live births in the 2008-10 triennium; thereafter it decreased to 146.7 in the 2011/12 period. The slow progress was due to the significant contribution of HIV/AIDs to maternal mortality and challenges in implementing the recommendations that were devised from the findings of the Enquiry. Nevertheless, the CEMD process has been maintained and strengthened so it is currently able to perform routine maternal death surveillance at both national and district levels, identify deficiencies within the health system, generate reports and also provide early warning about alarming trends such as the increasing numbers of deaths due to caesarean-section-associated haemorrhage.

Resilience in the time of crisis: A review of the maternal, perinatal and reproductive health effects of COVID-19 in South Africa.

BACKGROUND: The COVID-19 pandemic had a profound effect on the health sector globally and in South Africa (SA). OBJECTIVE: To review the effects of COVID-19 on maternal, perinatal and reproductive health outcomes and service utilisation in SA. METHODS: Three routine national data collection systems were sourced: the District Health Information System, the Saving Mothers reports of the National Committee on Confidential Enquiry into Maternal Deaths and the Saving Babies reports from the National Perinatal Morbidity and Mortality Committee using data from the Perinatal Problem Identification Program. RESULTS: There were 35% and 8% increases in maternal and stillbirth mortality rates, respectively, in 2020 and 2021, which correlated with the COVID-19 waves. However, in 2022, rates returned to pre-COVID levels. Antenatal visits and facility births showed little change, but there was a shift to more rural provinces. The use of oral and injectable contraceptives and termination of pregnancy services decreased markedly in 2020 and 2021, with a sustained shift to long-acting reversible contraceptives. The increase in maternal deaths was predominantly due to COVID-19 respiratory complications, but also an increase in obstetric haemorrhage. Stillbirths increased significantly (10%) for birthweights between 2 000 g and 2 499 g, categorised mostly as unexplained stillbirths or preterm labour, but no increase in neonatal deaths was observed. Administrative avoidable factors increased by 24% in the 2020 - 2022 triennium, but there was no increase in patient/community level or healthcare provider-related avoidable factors during the pandemic years. CONCLUSION: COVID-19 caused a marked increase in maternal death and stillbirth rates in 2020 and 2021 due to both direct effects of the virus and indirect effects on functioning of the health system. The continued, although modified, health-seeking behaviour of women and the rapid return to pre-COVID-19 mortality rates demonstrates enormous resilience in women and the health system.

Early Online: Vol. 114 No. 4.

Maternal healthcare in South Africa faces huge private and public health systems challenges. A key challenge for policy makers is how to address the inappropriate patterns of obstetric care in the private sector and how to mobilise private sector resources to serve the broader population dependent on the public sector, without replicating those patterns of inappropriate care. Developing and implementing new obstetric care models that address these challenges and lend themselves to public private engagements could play a vital role in efforts to improve obstetric care in the country. Drawing on insights from research we carried out on the care and contracting models used by five rural district hospitals in the Western Cape Province to contract private general practitioners to provide caesarean delivery services, this article outlines a potential alternative private sector obstetric care model with the aim of stimulating discussion by all relevant stakeholders on the development of new obstetric models for improving obstetric care in the country.

Implementing E-MOTIVE for detection and treatment of postpartum haemorrhage in South Africa.

Postpartum haemorrhage is the leading cause of preventable maternal mortality in South Africa. In a significant breakthrough in the management of PPH, the E-MOTIVE trial found that a multifaceted health service intervention reduced severe PPH after vaginal delivery by 60% in 78 hospitals in Nigeria, Kenya, Tanzania and SA. The E-MOTIVE approach comprises objective blood loss measurement monitored every 15 minutes during the first hour after delivery to detect PPH early and trigger a bundle of first-line treatments, including massaging the uterus, oxytocin infusion, tranexamic acid infusion, intravenous crystalloid fluids, examination for the cause, emptying the bladder and, if necessary, escalation of care. E-MOTIVE was integrated into the existing Essential Steps in Managing Obstetric Emergencies algorithm. Certain research-related elements of the trial setting cannot be replicated in routine practice. Therefore, we need to develop local strategies to ensure the essential clinical elements of the intervention are implemented. Potential strategies include incorporating the E-MOTIVE principles into national guidelines, ongoing training strategies and ensuring all facilities are equipped with necessary medication, equipment and delegations. This breakthrough intervention provides hope for women in SA, and requires a purposeful, co-ordinated implementation strategy on a national scale to reach all levels of the health service.

Caesarean section rates in South Africa: A case study of the health systems challenges for the proposed National Health Insurance.

Broader policy research and debate on the issues related to the planning of National Health Insurance (NHI) in South Africa (SA) need to be complemented by case studies to examine and understand the issues that will have to be dealt with at micro and macro levels. The objective of this article is to use caesarean section (CS) as a case study to examine the health systems challenges that NHI would need to address in order to ensure sustainability. The specific objectives are to: (i) provide an overview of the key clinical considerations related to CS; (ii) assess the CS rates in the SA public and private sectors; and (iii) use a health systems framework to examine the drivers of the differences between the public and private sectors and to identify the challenges that the proposed NHI would need to address on the road to implementation.

Maternal near-miss audit in the Metro West maternity service, Cape Town, South Africa: A retrospective observational study.

BACKGROUND: A maternal near-miss is defined as a life-threatening pregnancy-related complication where the woman survives. The World Health Organization (WHO) has produced a tool for identifying near-misses according to criteria that include the occurrence of a severe maternal complication together with organ dysfunction and/or specified critical interventions. Maternal deaths have been audited in the public sector Metro West maternity service in Cape Town, South Africa, for many years, but there has been no monitoring of near-misses. OBJECTIVES: To measure the near-miss ratio (NMR), maternal mortality ratio (MMR) and mortality index (MI), and to investigate the near-miss cases. METHODS: A retrospective observational study conducted during 6 months in 2014 identified and analysed all near-miss cases and maternal deaths in Metro West, using the WHO criteria. RESULTS: From a total of 19 222 live births, 112 near-misses and 13 maternal deaths were identified. The MMR was 67.6 per 100 000 live births and the NMR 5.83 per 1 000 live births. The maternal near-miss/maternal death ratio was 8.6:1 and the MI 10.4%. The major causes of near-miss were hypertension (n=50, 44.6%), haemorrhage (n=38, 33.9%) and puerperal sepsis (n=13, 11.6%). The first two conditions both had very low MIs (1.9% and 0%, respectively), whereas the figure for puerperal sepsis was 18.9%. Less common near-miss causes were medical/surgical conditions (n=7, 6.3%), non-pregnancy-related infections (n=2, 1.8%) and acute collapse (n=2, 1.8%), with higher MIs (33.3%, 66.7% and 33.3%, respectively). Critical interventions included massive blood transfusion (34.8%), ventilation (40.2%) and hysterectomy (30.4%). Considering health system factors, 63 near-misses (56.3%) initially occurred at a primary care facility, and the patients were all referred to the tertiary hospital; 38 (33.9%) occurred at a secondary hospital, and 11 (9.8%) at the tertiary hospital. Analysis of avoidable factors identified lack of antenatal clinic attendance (11.6%), inter-facility transport problems (6.3%) and health provider-related factors (25.9% at the primary level of care, 38.2% at secondary level and 7.1% at tertiary level). CONCLUSIONS: The NMR and MMR for Metro West were lower than in other developing countries, but higher than in high-income countries. The MI was low for direct obstetric conditions (hypertension, haemorrhage and puerperal sepsis), reflecting good quality of care and referral mechanisms for these conditions. The MIs for non-pregnancy-related infections, medical/surgical conditions and acute collapse were higher, suggesting that medical problems need more focused attention.

Magnesium supplementation and perinatal hypoxia: outcome of a parallel group randomised trial in pregnancy.

OBJECTIVE: To determine the effects of magnesium supplementation in pregnancy on the incidence of hypoxic-ischaemic encephalopathy (HIE). DESIGN: A randomised double-blind placebo-controlled study. SETTING: A Midwife Obstetric Unit and its two referral hospitals in Cape Town, South Africa. POPULATION: A group of 4494 black pregnant women of low socio-economic status. METHOD: Mothers, from the time of booking until delivery, were randomised to receive two identical tablets daily, containing either 128 mg slow-release magnesium stearate or lactose sugar. MAIN OUTCOME MEASURES: Primary: The incidence of HIE. Secondary: The incidence of fetal heart rate decelerations, term Stillbirths, Low Apgar Scores, Meconium Aspiration Pneumonia. RESULTS: The incidence of HIE (0.9%) was considerably less than anticipated (2%). There were 22 infants in the placebo group and 15 infants in the supplemented group (P = 0.279). The difference was not significant. Secondary outcomes such as late fetal heart rate decelerations (P = 0.002) and term stillbirths (P = 0.016) were reduced significantly in the supplemented group, but this finding needs further substantiation. CONCLUSIONS: Magnesium supplementation did not reduce the incidence of HIE significantly, probably because the study was underpowered and compliance was relatively poor.

Mid-upper arm circumference: A surrogate for body mass index in pregnant women.

BACKGROUND: Nutrition in pregnancy has implications for both mother and fetus, hence the importance of an accurate assessment at the booking visit during antenatal care. The body mass index (BMI, kg/m2) is currently the gold standard for measuring body fatness. However, pregnancy-associated weight gain and oedema, as well as late booking in our population setting, cause concern about the reliability of using the BMI to assess body fat or nutritional status in pregnancy. The mid-upper arm circumference (MUAC) has been used for many decades to assess malnutrition in children aged <5 years. Several studies have also shown a strong correlation between MUAC and BMI in both pregnant and non-pregnant adult populations. OBJECTIVE: To assess the correlation between the MUAC and BMI in pregnant women booking for antenatal care in the Metro West area of Cape Town, South Africa. METHODS: We conducted a cross-sectional study of women booking at four midwife obstetric units. Anthropometric measurements (height, weight and MUAC) were carried out on pregnant women at their first antenatal booking visit. RESULTS: The results showed a strong correlation between MUAC and BMI in pregnant women up to 30 weeks' gestation. The correlation was calculated at 0.92 for the entire group. The MUAC cut-offs for obesity (BMI >30) and malnutrition (BMI <18.5) were calculated as 30.57 cm and 22.8 cm, respectively. CONCLUSION: MUAC correlates strongly with BMI in pregnancy up to a gestation of 30 weeks in women attending Metro West maternity services. In low-resource settings, the simpler MUAC measurement could reliably be substituted for BMI to assess nutritional status.

Maternal deaths from bleeding associated with caesarean delivery: A national emergency.

Maternal deaths associated with caesarean deliveries (CDs) have been increasing in South Africa over the past decade. The objective of this report is to bring national attention to this increasing epidemic of maternal deaths due to bleeding associated with CD in the majority of provinces of the country. Individual chart reviews of women who died from bleeding at or after CD show that 71% had avoidable factors. Among the steps we can take are to improve surgical skills and experience, especially in rural hospitals, to improve clinical observations in the immediate postoperative period and in the postnatal wards, and to ensure that appropriate oxytocic agents are given to prevent postpartum haemorrhage. CEOs and medical managers of health facilities, district clinical specialists, heads of obstetrics and gynaecology, and midwifery training institutions must show leadership and accountability in providing an appropriate environment to ensure that women who require CD receive the procedure for the correct indications and in a safe manner to minimise risks.

Oxytocin--ensuring appropriate use and balancing efficacy with safety.

Maternal deaths due to haemorrhage continue to increase in South Africa (SA). It appears that oxytocin and other uterotonics are not being used optimally, even though they are an essential part of managing maternal haemorrhage. Oxytocin should be administered to every mother delivering in SA. Awareness is required of the side-effects that can occur and the appropriate measures to avoid harm from these. Second-line uterotonics should also be available and utilised in conjunction with mechanical and surgical means to arrest haemorrhage in women who continue to bleed after the appropriate administration of oxytocin.

Maternal death and caesarean section in South Africa: Results from the 2011-2013 Saving Mothers Report of the National Committee for Confidential Enquiries into Maternal Deaths.

BACKGROUND: In the latest (2011-2013) Saving Mothers report, the National Committee for Confidential Enquiries into Maternal Deaths in South Africa (SA) (NCCEMD) highlights the large number of maternal deaths associated with caesarean section (CS). The risk of a woman dying as a result of CS during the past triennium was almost three times that for vaginal delivery. Of all the mothers who died during or after a CS, 3.4% died during the procedure and 14.5% from haemorrhage afterwards. Including all cases of death from obstetric haemorrhage where a CS was done, there were 5.5 deaths from haemorrhage for every 10,000 CSs performed. OBJECTIVE: To scrutinise the contribution or effect of the surgical procedure on the ultimate cause of death by a cross-cutting analysis of the 2011-2013 national data. METHODS: Data from the 2011-2013 triennial review were entered into an Excel database and analysed on a national and provincial basis. RESULTS: There were 1,243 maternal deaths where a CS was the mode of delivery and 1 471 deaths after vaginal delivery. More mothers died as a result of CS in the provinces where there is a low overall CS rate. The following CS categories were identified as specific problems: bleeding during or after CS, pre-eclampsia and eclampsia, anaesthesia-related deaths, pregnancy-related sepsis and acute collapse and embolism. CONCLUSION: This is an area of concern, and a concentrated effort should be done to make CS in SA safer. Several recommendations are

The effect of calcium supplementation on blood pressure in non-pregnant women with previous pre-eclampsia: An exploratory, randomized placebo controlled study.

BACKGROUND: Epidemiological findings suggest that the link between poverty and pre-eclampsia might be dietary calcium deficiency. Calcium supplementation has been associated with a modest reduction in pre-eclampsia, and also in blood pressure (BP). METHODS: This exploratory sub-study of the WHO Calcium and Pre-eclampsia (CAP) trial aims to determine the effect of 500mg/day elemental calcium on the blood pressure of non-pregnant women with previous pre-eclampsia. Non-pregnant women with at least one subsequent follow-up trial visit at approximately 12 or 24weeks after randomization were included. RESULTS: Of 836 women randomized by 9 September 2014, 1st visit data were available in 367 women of whom 217 had previously had severe pre-eclampsia, 2nd visit data were available in 201 women. There was an overall trend to reduced BP in the calcium supplementation group (1-2.5mmHg) although differences were small and not statistically significant. In the subgroup with previous severe pre-eclampsia, the mean diastolic BP change in the calcium group (-2.6mmHg) was statistically larger than in the placebo group (+0.8mmHg), (mean difference -3.4, 95% CI -0.4 to -6.4; p=0.025). The effect of calcium on diastolic BP at 12weeks was greater than in those with non-severe pre-eclampsia (p=0.020, ANOVA analysis). CONCLUSIONS: There is an overall trend to reduced BP but only statistically significant in the diastolic BP of women with previous severe pre-eclampsia. This is consistent with our hypothesis that this group is more sensitive to calcium supplementation, however results need to be interpreted with caution.

Maternal mortality in rural and urban Zimbabwe: social and reproductive factors in an incident case-referent study.

A community-based incidence case-referent study was undertaken in a rural and an urban setting in Zimbabwe in order to define risk factors associated with maternal deaths at family, community, primary and referral health care levels. Referent subjects were drawn from place or area of delivery for each consecutive maternal death. Using a multiple source confidential reporting network for all maternal deaths, the maternal mortality rate for the rural setting was 168/100,000 live births and that for the urban setting was 85/100,000 live births. A model for interacting factors contributing to maternal mortality was designed. Haemorrhage and abortion sepsis were the major direct causes while malaria was the leading indirect cause in the rural setting. In the urban setting, eclampsia, abortion and puerperal sepsis were the leading causes of maternal deaths. It was found that all situations associated with diminished, or absent social support, that is, being single (Odds Ratio = 4.7, 95% CI = 2.2-9.8) divorced, widowed, one of several wives, cohabiting, or self-supporting carried an increased risk for maternal mortality, especially in the rural area. Income and level of education for index and referent subjects were comparable, probably because of the limited part of the population under study that belonged to a more affluent class. Distribution of cases and referents by religious-affiliation was also comparable. Age > 35 years and parity > 6 were significant risk factors for maternal mortality in the rural setting, whereas bad reproductive history with reported stillbirth or abortion constituted a high risk both in the city and in the rural areas (Odds Ratios 4-6).(ABSTRACT TRUNCATED AT 250 WORDS)

Oral misoprostol vs. placebo in the management of prelabor rupture of membranes at term.

OBJECTIVE: To evaluate the efficacy of oral misoprostol for the induction of labor (IOL) in women with prelabor rupture of membranes at term (PROM) and to monitor maternal or fetal complications. METHOD: This randomized, placebo controlled trial was performed in a secondary referral hospital. The data of 47 patients in the misoprostol--and 49 patients in the placebo group was available for analysis. The former received 100 microg misoprostol orally, repeated once after 6 h if not in active labor, the latter received two doses of vitamin C also after a 6-h interval. The Mann-Whitney U-test was used for analysis. RESULTS: The median treatment to delivery interval in the misoprostol group was 7.5 h and 25 h in the placebo group (P<0.001). No significant differences were found in the incidence of abnormalities on the cardiotocograph, mode of delivery, neonatal outcome, use of antibiotics for the mothers and patient acceptability. CONCLUSION: Oral misoprostol in the suggested dose is an effective and cheap alternative for IOL in patients with PROM. No adverse effects could be demonstrated.

Booked and unbooked mothers delivering at Harare Maternity Hospital, Zimbabwe: a comparison of maternal characteristics and foetal outcome.

This study was prompted by the poor maternal and foetal outcome at Harare Maternity Hospital, Zimbabwe, in unbooked mothers compared to women who had booked for antenatal care. Comparison was made of 195 recently delivered unbooked mothers with 196 booked mothers. Unbooked mothers were significantly more likely to be younger, of lower parity, be single, have lower socio-economic status, live in or migrate from rural areas, be uneducated and have an unwanted pregnancy. Their infants were significantly more likely to preterm and/or of low birth weight and had a higher perinatal mortality. The major reasons cited by the women for not booking were lack of money and delivery occurring before the intended time of booking. Discussion focuses on how to improve outcome in unbooked mothers.

PIP: Levels of perinatal and maternal mortality in the Greater Harare Maternity Unit in Harare, Zimbabwe, are markedly higher among women who do not book for antenatal care compared to women who do book. The authors used a case-control approach to determine which factors are related to unbooked and booked mothers, respectively, and reasons for the failure to book for antenatal care. 195 recently delivered unbooked mothers were compared against 196 booked mothers over the period January-March 1986, during which there were a total of 40,379 deliveries at the hospital. Data were collected via personal interview on the day of delivery or the day after. Unbooked mothers were significantly more likely to be younger, of lower parity, single, of lower socioeconomic status, live in or migrate from rural areas, be uneducated, and have an unwanted pregnancy. Their infants were significantly more likely to be preterm and/or of low birth weight and had an higher level of perinatal mortality. Major reasons cited by the women for not booking were lack of money and delivery occurring before the intended time of booking. The discussion focuses upon how to improve outcomes in unbooked mothers. Unbooked mothers are an high-risk group which should be targeted for antenatal care and early booking. Concern is also expressed that the universal introduction of user charges for maternity care under the Economic Structural Adjustment Program will further deter the high-risk group from availing themselves of antenatal care.

Integration of family planning into maternal and child health and other services at Harare Central Hospital.

PIP: To increase the accessibility, availability, and acceptance of family planning methods and counseling, family planning services were integrated with maternal and child health care services at Harare Central Hospital in Zimbabwe. The Family Planning Project was implemented with hopes that mothers would seek contraceptive methods and counseling concurrent with their or their children's hospital admission, thereby making facility and service inaccessibility a thing of the past. Ante-natal, post-natal, and postabortal women were targeted for project outreach at the facility, along with patients suffering chronic medical and psychiatric problems, and mothers of malnourished children. Weaknesses of family planning provision at the hospital prior to the project are presented in the component parts of pharmacy, emergency gynecology unit, outpatient department, ante-natal clinic, post-partum care, post-natal clinic, and the general hospital. 2 full-time nurse- midwives and 2 part-time gynecologists counsel and provide services for the Family Planning Project. Other programmatic changes and improvements are described. There were 3,822 new acceptors and 5,423 return visits during the 1st project year, with the nurse-midwives providing 3,114 couple-years of protection, equal to 5.1% of the total provided by all 35 national family planning council clinics. Additional results, plans for the future, and problem areas are further discussed. The project, undertaken with few resources and high motivation, yielded high family planning acceptance rates with markedly less inconvenience for acceptors.^ieng

A community based investigation of causes of maternal mortality in rural and urban Zimbabwe. Maternal Mortality Study Group.

UNLABELLED: Most data on maternal mortality in Zimbabwe has been urban hospital based. Using a network of informants and sensitized health workers an attempt was made to identify and investigate all maternal deaths in rural Masvingo and urban Harare over a two year period. The present report discusses place of death and the medical causes in both populations. Results gave maternal mortality rates of 168 and 85 per 100,000 live births for Masvingo and Harare respectively. These rates are significantly higher than those from conventional reporting systems especially in the rural area where 27 pc of deaths occurred at home or in transit. The leading medical causes of death were haemorrhage in Masvingo (25 pc of deaths) and eclampsia in Harare (26 pc), with puerperal and post abortal sepsis as the next most common causes in both cases. Malaria featured as the major indirect cause in Masvingo (7.6 pc). There were four suicides committed following unwanted pregnancy. The rural/urban variation in causation of death is discussed and the study results compared with other community based studies internationally. SYNOPSIS: This community based study revealed higher maternal mortality rates (MMR) than conventional statistics, especially in the rural area where deaths occurred at home or in transit. In the rural area the MMR was higher and the leading cause of death was haemorrhage, compared to eclampsia in the urban area. Strategies to reduce maternal deaths should include factors both within and outside health service structures.

Low birth weight in urban Harare.

OBJECTIVES: 1. To measure the incidence of low birth weight from all institutional deliveries in a defined catchment area of urban Harare. 2. To estimate the relative proportions of preterm and small for gestational age (SGA). DESIGN: The study was descriptive and was conducted during the last three months of 1986. SETTING: The low risk maternity units in three high density suburbs, Highfield, Glen Norah and Glen View and the referral centre Harare Central Hospital. SUBJECTS: All babies born to women residing in the study areas in the maternity clinics and those transferred to the referral hospital were identified and weighed. MAIN OUTCOME MEASURES: For low birthweight babies gestation was estimated by the Dubowitz method and perinatal outcome was recorded. RESULTS: During the three month study period in 1986, 2,056 babies in total were born; 223 (10.8%) of which were low birthweight. Of these 65 (44%) were preterm and 55 (37%) were SGA. CONCLUSION: The findings show a lower percentage of low birthweight and SGA babies than in many developing countries but higher than the norm for developed countries. The study demonstrates a need for resources to prevent low birthweight delivery and improve care for low birthweight babies.

PIP: A 1986 descriptive study of all institutional deliveries in a defined catchment area of urban Harare, Zimbabwe, investigated the incidence of low birth weight (LBW, under 2500 grams), and the relative contributions of preterm and small-for-gestational-age (SGA, gestational age 37 weeks or above plus LBW) deliveries to LBW. Since most LBW statistics are based on deliveries from central hospitals that serve as referral centers for distant rural areas, they cannot be considered representative of a particular urban population. The high-density, low-income Harare suburbs of Highfield, Glen Norah, and Glen View were selected for the analysis. During the 3-month study period, there were 2056 registered births in the 3 communities. 1101 of these deliveries occurred at the 3 low-risk maternal clinics serving these areas and 955 took place, after referral, at the high-risk Harare Central Hospital. There were 223 LBW infants (10.8%), 50 of whom were delivered in the clinics and 173 in the referral hospital. All 17 infants weighing under 1000 grams were delivered at the hospital. 148 LBW infants (including 13 stillbirths, 6 early neonatal deaths, and 14 sets of twins) were selected for further study. 44% of these infants were preterm and 37% were SGA; the remainder were appropriate for gestational age. When the data were adjusted to conform with the Villa/Belizan categories, 5.3% were LBW/preterm and 5.5% were LBW/intrauterine growth retardation. Overall, the LBW pattern identified in this study falls between that of a developed and a developing country, which is presumably reflective of the high level of general development in Harare.