A synthesis of clinical and health system bottlenecks to implementing new WHO postpartum hemorrhage recommendations: Secondary data analysis of the Kenya Confidential Enquiry into Maternal Deaths 2014-2017.

OBJECTIVE: To describe maternal deaths from postpartum hemorrhage (PPH) in Kenya by secondary analysis of the Kenya Confidential Enquiry into Maternal Deaths (CEMD) database and clinical audit of a sample of those deaths, and to identify the perceived challenges to implementing country-specific PPH guidelines. METHODS: A retrospective descriptive study using the Kenyan CEMD database and anonymized maternal death records from 2014-2017. Eight standards from the Kenya National Guidelines for Quality Obstetric and Perinatal Care were selected to perform clinical audit. The process of supporting eight Sub-Saharan African countries to develop country-specific PPH guidelines was described and perceived challenges implementing these were identified. RESULTS: In total, 725 women died from PPH. Most women attended at least one antenatal care visit (67.2%) and most did not receive iron and folate supplementation (35.7%). Only 39.0% of women received prophylactic uterotonics in the third stage of labor. Factors significantly associated with receiving prophylactic uterotonics were place of delivery (χ2  = 43.666, df = 4; P < 0.001), being reviewed by a medical doctor (χ2  = 16.905, df = 1; P < 0.001), and being reviewed by a specialist (χ2  = 49.244, df = 1; P < 0.001). Only three of eight standards had a greater percentage of met cases in comparison to unmet cases. Key concerns about implementation of the new WHO PPH guidance included use of misoprostol by unskilled health personnel, availability of misoprostol and tranexamic acid (TXA) at primary healthcare level, lack of availability of heat-stable carbetocin (HSC) due to cost, lack of awareness and education about HSC and TXA, and lack of systems to ensure quality oxytocin is available at point of care. CONCLUSION: There is a need for improved quality of care for women to minimize the risk of mortality from PPH, by implementing updated clinical guidelines combined with focused health system interventions.

Reducing maternal and child mortality in rural Ghana.

The lack of health infrastructure in developing countries to provide women with modern obstetric care and universal access to maternal and child health services has largely contributed to the existing high maternal and infant deaths. Access to basic obstetric care for pregnant women and their unborn babies is a key to reducing maternal and infants´ deaths, especially at the community-level. This calls for the strengthening of primary health care systems in all developing countries, including Ghana. Financial access and utilization of maternal and child health care services need action at the community-level across rural Ghana to avoid preventable deaths. Financial access and usage of maternal and child health services in rural Ghana is poor. Lack of financial access is a strong barrier to the use of maternal and child health services, particularly in rural Ghana. The sustainability of the national health insurance scheme is vital in ensuring full access to care in remote communities.

The Essential Role of Nurse Practitioners and Midwives on Maternal Mortality Review Committees.

Rates of maternal morbidity and mortality in the United States continue to rise, and three out of every five U.S. pregnancy-related deaths are preventable. A multiprong approach to addressing this public health crisis is needed, including the development and activation of maternal mortality review committees, which can systematically assess maternal deaths and recommend systemic-based interventions and policy changes to reverse this trend. Women's health nurse practitioners and midwives are uniquely positioned to provide insight to maternal mortality review committees, given their holistic approach and person-centered philosophy of care. The Washington State Department of Health developed a robust committee that uses women's health nurse practitioners and midwives in its review and may serve as a model for other state organizations.

Health providers´ knowledge on maternal and newborn care: implications on health systems strengthening in Vihiga County, Kenya.

INTRODUCTION: pregnant women need access to skilled attendance at birth and emergency obstetric care (EmOC) to avert maternal deaths. While poor EmOC services may explain the high maternal mortality, inadequate knowledge of providers is also part of the problem. This forms the basis of this paper, in a setting where 50.2% of women deliver in a health facility but maternal mortality remains high at 531/100,000 live births, compared to the national average of 362/100,000 in Kenya. METHODS: a facility based cross-sectional survey was conducted in 2018 with a set of knowledge questions extracted from the averting maternal death and disability toolkit. Providers knowledge for maternal and newborn health (MNH) was assessed by interviewing nurses on duty in the maternity units. Data were entered in Ms Access and exported to R version 3.6.2 for descriptive and logistic regression analysis. Ethical clearance was obtained from Kenya Medical Research Unit. RESULTS: a total of 55 nurses were interviewed. Majority (71%) of the respondents were diploma nurses. The overall knowledge score for MNH among the providers was adequate with a score of (64%). Generally, the midwives and higher diploma nurses consistently scored higher than diploma nurses in all the topic areas of MNH. In the mixed linear regression, determinants of knowledge score were seen in provider-level variables. CONCLUSION: overall, the providers scores were higher on intrapartum and newborn care compared to scores on care for complications. We conclude that in-service training on EmOC to providers is critical to reduction of maternal mortality.

The influence of quality and respectful care on the uptake of skilled birth attendance in Tanzania.

BACKGROUND: An increase in the uptake of skilled birth attendance is expected to reduce maternal mortality in low- and middle-income countries. In Tanzania, the proportion of deliveries assisted by a skilled birth attendant is only 64% and the maternal mortality ratio is still 398/100.000 live births. This article explores different aspects of quality of care and respectful care in relation to maternal healthcare. It then examines the influence of these aspects of care on the uptake of skilled birth attendance in Tanzania in order to offer recommendations on how to increase the skilled birth attendance rate. METHODS: This narrative review employed the "person-centered care framework for reproductive health equity" as outlined by Sudhinaraset (2017). Academic databases, search engines and websites were consulted, and snowball sampling was used. Full-text English articles from the last 10 years were included. RESULTS: Uptake of skilled birth attendance was influenced by different aspects of technical quality of maternal care as well as person-centred care, and these factors were interrelated. For example, disrespectful care was linked to factors which made the working circumstances of healthcare providers more difficult such as resource shortages, low levels of integrated care, inadequate referral systems, and bad management. These issues disproportionately affected rural facilities. However, disrespectful care could sometimes be attributed to personal attitudes and discrimination on the part of healthcare providers. Dissatisfied patients responded with either quiet acceptance of the circumstances, by delivering at home with a traditional birth attendant, or bypassing to other facilities. Best practices to increase respectful care show that multi-component interventions are needed on birth preparedness, attitude and infrastructure improvement, and birth companionship, with strong management and accountability at all levels. CONCLUSIONS: To further increase the uptake of skilled birth attendance, respectful care needs to be addressed within strategic plans. Multi-component interventions are required, with multi-stakeholder involvement. Participation of traditional birth attendants in counselling and referral can be considered. Future advances in information and communication technology might support improved quality of care.

Can Women's Lives be saved from Hypertensive Disorders during Pregnancy? Experiences of South African Midwives.

A qualitative, descriptive phenomenological research design was conducted to explore and describe the experiences of midwives on the management of women diagnosed with hypertensive disorders during pregnancy in rural areas of Limpopo Province, South Africa. Non-probability sampling was used to select eighteen (18) midwives from primary health care facilities of Mopani and Vhembe districts in Limpopo Province. Data was collected through in-depth interview and analysed using eight steps of Tesch's open coding method. Ethical considerations were adhered to by ensuring confidentiality, anonymity, privacy and signing of informed consent by participants. Measures to ensure trustworthiness; credibility, transferability, dependability and lastly, confirmability were ensured. Findings of this study revealed three themes (with sub-themes) namely; management of pregnant women diagnosed with hypertensive disorders, support experienced when managing complications, challenges experienced by midwives when managing hypertensive disorders during pregnancy. In conclusion, poor support came up very strongly as a factor influencing good management of hypertensive disorders in pregnancy. Recruitment of more midwives that will support each other during management of pregnant women with hypertensive disorders is recommended.

Changing the conversation: applying a health equity framework to maternal mortality reviews.

The risk of maternal death in the United States is higher than peer nations and is rising and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual's risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death and, when appropriate, to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the community vital signs, the social and community context in which women live, work, and seek health care, maternal mortality review committees may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.

Understanding the gap in emergency obstetric and neonatal care in Ghana through the PREventing Maternal And Neonatal Deaths (PREMAND) study.

OBJECTIVE: To explore basic and comprehensive emergency obstetric service provision across four districts in rural northern Ghana, and whether women were more likely to deliver at facilities with more skilled care. METHODS: Field workers geo-coded all health facilities in East Mamprusi, Sissala East, Kassena Nankana Municipal, and Kassena Nankana West districts, and administered surveys to assess providers and emergency obstetric care available. Data were also prospectively collected on delivery locations of women and neonates who died, or nearly died (near misses), between September 1, 2015 and April 30, 2017. RESULTS: There were 14 physicians for a population of nearly 360 000 women. Six (6%) facilities could provide basic emergency care, and 3 (3%) could provide comprehensive care. Services were distributed unequally, with 6 (67%) of the emergency facilities located in the least populated district. Among the sample of women and neonates who died or nearly died, 175 (39%) delivered at locations unable to provide basic emergency services. CONCLUSION: Access to emergency obstetric and neonatal care was distributed inequitably across these districts, suggesting the need to revisit geographic placement of facilities relative to population. The study also raised the question of how to ensure facilities are equipped to respond to emergencies.

Scaling Up Misoprostol to Prevent Postpartum Hemorrhage at Home Births in Mozambique: A Case Study Applying the ExpandNet/WHO Framework.

BACKGROUND: Mozambique has a high maternal mortality ratio, and postpartum hemorrhage (PPH) is a leading cause of maternal deaths. In 2015, the Mozambican Ministry of Health (MOH) commenced a program to distribute misoprostol at the community level in selected districts as a strategy to reduce PPH. This case study uses the ExpandNet/World Health Organization (WHO) scale-up framework to examine the planning, management, and outcomes of the early expansion phase of the scale-up of misoprostol for the prevention of PPH in 2 provinces in Mozambique. METHODS: Qualitative semistructured interviews were conducted between February and October 2017 in 5 participating districts in 2 provinces. Participants included program stakeholders, health staff, community health workers (CHWs), and traditional birth attendants (TBAs). Interviews were analyzed using the ExpandNet/WHO framework alongside national policy and planning documents and notes from a 2017 national Ministry of Health maternal, newborn, and child health workshop. Outcomes were estimated using misoprostol coverage and access in 2017 for both provinces. RESULTS: The study revealed a number of barriers and facilitators to scale-up. Facilitators included a supportive political and legal environment; a clear, credible, and relevant innovation; early expansion into some Ministry of Health systems and a strong network of CHWs and TBAs. Barriers included a reduction in reach due to a shift from universal distribution to application of eligibility criteria; fear of misdirecting misoprostol for abortion or labor induction; limited communication and understanding of the national PPH prevention strategy; inadequate monitoring and evaluation; challenges with logistics systems; and the inability to engage remote TBAs. Lower coverage was found in Inhambane province than Nampula province, possibly due to NGO support and political champions. CONCLUSION: This study identified the need for a formal review of the misoprostol program to identify adaptations and to develop a systematic scale-up strategy to guide national scale-up.

Knowledge of intrapartum care among obstetric care providers in rural Kenya.

BACKGROUND: Kenya did not meet its maternal mortality ratio (MMR) target under the Millennium Development Goals. The aim of this study was to examine the gaps in knowledge of intrapartum care among obstetric care providers (OCPs) in rural Nandi County, Kenya. METHODS: This cross-sectional study in 2015 surveyed 326 nurses, midwives, clinical officers and physicians about their knowledge, attitudes and practices related to normal labor and childbirth, immediate newborn care and management of obstetric complications. RESULTS: Self-reported intrapartum knowledge among OCPs was insufficient according to accepted international standards. The mean total knowledge score for all OCPs based on a validated 30-question inventory was 62% (range 23-90%). Only 14 providers (4%) scored as 'competent' (a score ≥80%). Scores were higher for OCPs who had received pre- and postemployment emergency obstetric care training and those with higher levels of confidence in their skills. Survey respondents identified a lack of knowledge as one of the greatest barriers to high-quality patient care. CONCLUSIONS: Increasing training opportunities for OCPs may improve the quality of obstetric care provided to women in Kenya and other high-MMR locations in sub-Saharan Africa and enable progress toward achieving the ambitious Sustainable Development Goals target for maternal survival.

Obstetrics knowledge and skills training as a catalyst for change.

BACKGROUND: Poor emergency obstetric care has been shown by national confidential enquiries into maternal deaths to contribute to a number of maternal deaths in South Africa. OBJECTIVES: To assess whether a structured training course can improve knowledge and skills and whether this can influence the capacity of a healthcare facility to provide basic and comprehensive emergency obstetric care signal functions. METHODS: A baseline survey was conducted to assess the seven basic emergency obstetric and neonatal care signal functions in 51 community health centres (CHCs) and the nine comprehensive emergency care signal functions in 62 district hospitals (DHs). A re-assessment was conducted 1 year after saturation training had been provided in each district. The delegates were trained using a structured training programme (Essential Steps in Managing Obstetric Emergencies, ESMOE) and their knowledge and skills were tested before and after the training. Saturation training was considered to have been achieved once 80% of the healthcare professionals involved in maternity care had been trained. RESULTS: There was a significant improvement in the knowledge and skills of doctors, namely by 16.8% and 32.8%, respectively, of advanced midwives by 13.7% and 29.0%, and of professional nurses with midwifery by 16.1% and 31.2%. The seven basic emergency care functions improved from 60.8% to 67.8% in the CHCs and from 90.7% to 92.5% in the DHs before and after training. If the two signal functions that are not within the scope of practice of professional nurses with midwifery are excluded (viz. assisted delivery and manual vacuum aspiration), the functionality of CHCs increased from 85.1% to 94.9%. CONCLUSIONS: The ESMOE training programme improved knowledge and skills, but there was a modest improvement in the functionality of the facilities. Improvement in functionality requires changes in the structure of the health system, including changing the scope of practice of professional nurses with midwifery and employing more advanced midwives in CHCs.

Effects of limited midwifery clinical education and practice standardisation of student preparedness.

AIM: To explore the perceptions of midwifery educators regarding effects of limited standardisation of midwifery clinical education and practice on clinical preparedness of midwifery students. BACKGROUND: Investigation of levels of clinical competency of students is a critical need in the current era. Such competency levels are especially important in midwifery practice in South Africa as there is a significant increase of maternal deaths and litigations in the country. Most of the deaths are in the primary healthcare level maternity units where the newly qualified midwives practise. These areas are mainly run by midwives only. The current article seeks to report the findings of the study that was conducted to investigate how midwifery educators prepare students adequately for clinical readiness. SETTINGS: The study was conducted amongst midwifery nurse educators on three campuses of the Nursing College in the Eastern Cape. DESIGN: A qualitative, explorative, descriptive and contextual research design was used for the study. DATA SOURCES AND METHODS: Seventeen purposively selected midwifery educators, with the researcher using set criteria, from a Nursing college in the Eastern Cape, were the participants in the study. Data was collected using focus-group interviews that were captured by means of an audio-voice recorder. Tesch's data-analysis method was used to develop themes and sub-themes. Trustworthiness of the study was ensured using the criteria of credibility, transferability, dependability and confirmability. RESULTS: Inconsistent clinical practice amongst midwifery educators in their clinical teaching and assessment were found to be the major factors resulting from limited standardisation. The inconsistent clinical practice and assessments of midwifery educators was found to lead to loss of the necessary skills required by the students which led them to perform poorly in their final clinical assessments. CONCLUSION: There are some barriers in the current clinical teaching and education strategy used in this college that prohibit the production of confident, independent, and safe practitioners as planned. Midwifery educators need to be assisted in reviewing the current teaching strategy. Furthermore management should be involved if not the initiators of that reviewing and should put in-place new measures to support the teaching of the clinical module.

Reducing Maternal Deaths in Ethiopia: Results of an Intervention Programme in Southwest Ethiopia.

BACKGROUND: In a large population in Southwest Ethiopia (population 700,000), we carried out a complex set of interventions with the aim of reducing maternal mortality. This study evaluated the effects of several coordinated interventions to help improve effective coverage and reduce maternal deaths. Together with the Ministry of Health in Ethiopia, we designed a project to strengthen the health-care system. A particular emphasis was given to upgrade existing institutions so that they could carry out Basic (BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC). Health institutions were upgraded by training non-clinical physicians and midwives by providing the institutions with essential and basic equipment, and by regular monitoring and supervision by staff competent in emergency obstetric work. RESULTS: In this implementation study, the maternal mortality ratio (MMR) was the primary outcome. The study was carried out from 2010 to 2013 in three districts, and we registered 38,312 births. The MMR declined by 64% during the intervention period from 477 to 219 deaths per 100,000 live births (OR 0.46; 95% CI 0.24-0.88). The decline in MMR was higher for the districts with CEmOC, while the mean number of antenatal visits for each woman was 2.6 (Inter Quartile Range 2-4). The percentage of pregnant women who attended four or more antenatal controls increased by 20%, with the number of women who delivered at home declining by 10.5% (P<0.001). Similarly, the number of deliveries at health posts, health centres and hospitals increased, and we observed a decline in the use of traditional birth attendants. Households living near to all-weather roads had lower maternal mortality rates (MMR 220) compared with households without roads (MMR 598; OR 2.72 (95% CI 1.61-4.61)). CONCLUSIONS: Our results show that it is possible to achieve substantial reductions in maternal mortality rates over a short period of time if the effective coverage of well-known interventions is implemented.

Preventing deaths due to the hypertensive disorders of pregnancy.

In this chapter, taking a life cycle and both civil society and medically oriented approach, we will discuss the contribution of the hypertensive disorders of pregnancy (HDPs) to maternal, perinatal and newborn mortality and morbidity. Here we review various interventions and approaches to preventing deaths due to HDPs and discuss effectiveness, resource needs and long-term sustainability of the different approaches. Societal approaches, addressing sustainable development goals (SDGs) 2.2 (malnutrition), 3.7 (access to sexual and reproductive care), 3.8 (universal health coverage) and 3c (health workforce strengthening), are required to achieve SDGs 3.1 (maternal survival), 3.2 (perinatal survival) and 3.4 (reduced impact of non-communicable diseases (NCDs)). Medical solutions require greater clarity around the classification of the HDPs, increased frequency of effective antenatal visits, mandatory responses to the HDPs when encountered, prompt provision of life-saving interventions and sustained surveillance for NCD risk for women with a history of the HDPs.

Preventing deaths due to haemorrhage.

Prevention of deaths from obstetric haemorrhage requires effective health systems including family planning, commodities, personnel, infrastructure and ultimately universal access to comprehensive obstetric care for women giving birth. The main causes of death associated with antepartum haemorrhage are placental abruption, placenta praevia and uterine rupture. Preventive measures include preconceptual folate supplementation, management of hypertensive disorders, early diagnosis of placenta praevia and use of uterine stimulants cautiously, particularly misoprostol. Preventive measures for post-partum haemorrhage include routine active management of the third stage of labour. Treatment involves a cascade of increasingly invasive interventions in rapid sequence until the bleeding is stopped. These interventions include fluid resuscitation, removal of the placenta, bimanual uterine compression, uterotonics, tranexamic acid, suturing of lower genital tract injury, blood product replacement, balloon tamponade, laparotomy, stepwise uterine devascularization, uterine compression sutures and hysterectomy. Emergency temporizing measures include application of the non-pneumatic anti-shock garment, and at laparotomy, aortic compression and uterine tourniquet application. The effectiveness of treatment methods and the optimal dosage of misoprostol are research priorities. Interesting new approaches include transvaginal uterine artery clamping and suction uterine tamponade.

Millennium development Goal 5: progress and challenges in reducing maternal deaths in Ghana.

BACKGROUND: High maternal deaths in developing countries are recognised as a public health issue. To address this concern, targets were set as part of the Millennium Development Goals, launched in 2000 by the United Nations General Assembly. However, despite focused efforts, the maternal health targets in developing regions may not be achieved by 2015. DISCUSSION: We highlight progress and challenges in reducing maternal deaths, with a particular focus on Ghana. We discuss key issues like the free maternal healthcare package, transportation and referral concerns, human resources challenges, as well as the introduction of direct-entry midwifery training and the Community-based Health and Planning Services rolled out to specifically help curb poor maternal health outcomes. A key contribution to the country's slow progress towards achieving Millennium Development Goal 5 is that policy choices have often been in response to emergency or advancing problems rather than the use of preventive measures. Ghana can benefit greatly from long-term preventive strategies, the development of human resources, infrastructure and community health education.

Misoprostol for Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan: Program Expansion Experience.

INTRODUCTION: Afghanistan has a maternal mortality ratio of 400 per 100,000 live births. Hemorrhage is the leading cause of maternal death. Two-thirds of births occur at home. A pilot program conducted from 2005 to 2007 demonstrated the effectiveness of using community health workers for advance distribution of misoprostol to pregnant women for self-administration immediately following birth to prevent postpartum hemorrhage. The Ministry of Public Health requested an expansion of the pilot to study implementation on a larger scale before adopting the intervention as national policy. The purpose of this before-and-after study was to determine the effectiveness of advance distribution of misoprostol for self-administration across 20 districts in Afghanistan and identify any adverse events that occurred during expansion. METHODS: Cross-sectional household surveys were conducted pre- (n = 408) and postintervention (n = 408) to assess the effect of the program on uterotonic use among women who had recently given birth. Maternal death audits and verbal autopsies were conducted to investigate peripartum maternal deaths that occurred during implementation in the 20 districts. RESULTS: Uterotonic use among women in the sample increased from 50.3% preintervention to 74.3% postintervention. Because of a large-scale investment in Afghanistan in training and deployment of community midwives, it was assumed that all women who gave birth in facilities received a uterotonic. A significant difference in uterotonic use at home births was observed among women who lived farthest from a health facility (> 90 minutes self-reported travel time) compared to women who lived closer (88.5% vs 38.9%; P < .0001). All women who accepted misoprostol and gave birth at home used the drug. No maternal deaths were identified among those women who used misoprostol. DISCUSSION: The results of this study build on the findings of the pilot program and provide evidence on the effectiveness, primarily measured by uterotonic use, of an expansion of advance distribution of misoprostol for self-administration.

Making it happen: a programme of education in Kenya.

The number of mothers and babies from the developing world who die in pregnancy and childbirth remains unacceptably high. However, concerted efforts over the last 20 years to reduce the number of deaths have produced significant results, leading to a steady fall in maternal and neonatal mortality rates since 1990 (Unicef 2014). One initiative that is having an impact is the 'Making it happen' programme funded by the UK government and run by Liverpool's School of Tropical Medicine. A 'skills and drills'-type course covering obstetric and neonatal emergencies is delivered to health professionals across Sub-Saharan Africa and Asia. This article describes the volunteer experience of a UK midwife helping to facilitate a course in Kenya, which has some of the world's poorest health outcomes.