Analysis of maternal mortality in Berlin, Germany - discrepancy between reported maternal mortality and comprehensive death certificate exploration.

OBJECTIVES: The Organisation for Economic Cooperation and Development (OECD) estimates an average maternal mortality rate (MMR) of around 3.4 maternal deaths per 100,000 live births for 2019-2021, based on relevant diagnoses on death certificates. However, Germany does not currently have a registry for recording the number of maternal deaths. The aim of this study is to identify the actual number of maternal deaths in Berlin between 2019 and 2022, as well as sources of underreporting and causes of death. METHODS: Potential maternal mortality cases were identified through a search at the Berlin Central Archive for Death Certificates, inquiring women aged 15-50 years with indications of present or recent pregnancy on the death certificate. To cross match the database, an additional search at the Charité University Hospital Berlin was carried out, checking each individual file for pregnancy-association. RESULTS: The data search resulted in 2,316 women, 18 of which presented an association to pregnancy. Of these, 12 could be classified as maternal mortality cases (MMR 7.8/100,000). The additional search in a university setting revealed two further maternal mortality cases without prior indication of pregnancy on the death certificate. This results in a total MMR of 9.1/100,000 live births, which is over double the official estimate by the OECD. CONCLUSIONS: Based on our findings in Berlin, it can be estimated that there is significant underreporting regarding maternal death cases in Germany. A more comprehensive recording system is needed to more accurately portray maternal mortality.

Challenges faced by midwives in the implementation of facility-based maternal death reviews in Malawi.

BACKGROUND: Maternal death reviews provide an in-depth understanding of the causes of maternal deaths. Midwives are well positioned to contribute to these reviews. Despite midwives' participation as members of the facility-based maternal death review team, maternal mortality continues to occur, therefore, this study aimed to explore the challenges faced by midwives as they participate in maternal death reviews in the context of the healthcare system in Malawi. METHODS: This was a qualitative exploratory study design. Focus group discussions and individual face-to-face interviews were used to collect data in the study. A total of 40 midwives, who met the inclusion criteria, participated in the study. Data was analyzed manually using a thematic content procedure. RESULTS: Challenges identified were: knowledge and skill gaps; lack of leadership and accountability; lack of institutional political will and inconsistency in conducting FBMDR, impeding midwives' effective contribution to the implementation of maternal death review. The possible solutions and recommendations that emerged were need-based knowledge and skills updates, supportive leadership, effective and efficient interdisciplinary work ethics, and sustained availability of material and human resources. CONCLUSION: Midwives have the highest potential to contribute to the reduction of maternal deaths. Practice development strategies are required to improve their practice in all the areas they are challenged with.

Reducing maternal mortality: a 10-year experience at Mpilo Central Hospital, Bulawayo, Zimbabwe.

OBJECTIVES: Maternal mortality is one of the major Sustainable Development Goals (SDGs) of the global health community. The aim of the SDG 3.1 is to reduce global maternal mortality ratio considerably by 2030. The objective of this study was to document the epidemiological trends in maternal mortality for Mpilo Central Hospital. METHODS: This was a 10 year retrospective study using readily available data from the maternity registers. The International Classification of Diseases-Maternal Mortality (ICD-MM) coding system for maternal deaths was used. RESULTS: The maternal mortality ratio (MMR) declined from 655 per 100,000 live births in 2011 to 203 per 100,000 live births by 2020. The commonest groups of maternal mortality during the period 2011-2020 were hypertensive disorders, obstetric haemorrhage, pregnancy-related infection, and pregnancies with abortive outcomes. There were 273 maternal deaths recorded in the period 2011-2015, and 168 maternal deaths in the period 2016-2020. There was also a decline in maternal deaths due to obstetric haemorrhage (53 vs. 34). Maternal deaths due to pregnancy-related infection also declined (46 vs. 22), as well as pregnancies with abortive outcomes (40 vs. 26). CONCLUSIONS: There was a 69% decline in the MMR over the 10 year period. The introduction of government interventions such as malarial control, the adoption of life-long Option B+ antiretroviral treatment for the pregnant women, the training courses of staff, and the introduction of strong clinical leadership and accountability were all associated with a significant decline in the causes of maternal deaths.

Predictors and causes of in-hospital maternal deaths within 120 h of admission at a tertiary hospital in South-Western, Nigeria: A retrospective cohort study.

Background: An efficient, comprehensive emergency obstetrics care (CEMOC) can considerably reduce the burden of maternal mortality (MM) in Nigeria. Information about the risk of maternal death within 120 h of admission can reflect the quality of CEMOC offered. Aim: This study aims to determine the predictors and causes of maternal death within 120 h of admission at the Lagos University Teaching Hospital, LUTH, Lagos South-Western, Nigeria. Methods: We conducted a retrospective cohort study amongst consecutive maternal deaths at a hospital in South-Western Nigeria, from 1 January 2007 to 31 December 2017, using data from patients' medical records. We compared participants that died within 120 h to participants that survived beyond 120 h. Survival life table analysis, Kaplan-Meier plots and multivariable Cox proportional hazard regression were conducted to evaluate the factors affecting survival within 120 h of admission. Stata version 16 statistical software (StatCorp USA) was used for analysis. Results: Of the 430 maternal deaths, 326 had complete records. The mean age of the deceased was 30.7± (5.9) years and median time to death was 24 (5-96) h. Two hundred and sixty-eight (82.2%) women out of 326 died within 120 h of admission. Almost all maternal deaths from uterine rupture (95.2%) and most deaths from obstetric haemorrhage (87.3%), induced miscarriage (88.9%), sepsis (82.9%) and hypertensive disorders of pregnancy (77.9%) occurred within 120 h of admission. Admission to the intensive care unit (P = 0.007), cadre of admitting doctor (P < 0.001), cause of death (P = 0.036) and mode of delivery (P = 0.012) were independent predictors of hazard of death within 120 h. Conclusion: The majority (82.2%) of maternal deaths occurred within 120 h of admission. Investment in the prevention and acute management of uterine rupture, obstetric haemorrhage, sepsis and hypertensive disorders of pregnancy can help to reduce MM within 120 h in our environment.

Clinical characteristics, outcomes, & mortality in pregnant women with COVID-19 in Maharashtra, India: Results from PregCovid registry.

Background & objectives: The PregCovid registry was established to document the clinical presentations, pregnancy outcomes and mortality of pregnant and post-partum women with COVID-19. Methods: The PregCovid registry prospectively collects information in near-real time on pregnant and post-partum women with a laboratory-confirmed diagnosis of SARS-CoV-2 from 19 medical colleges across the State of Maharashtra, India. Data of 4203 pregnant women collected during the first wave of the COVID-19 pandemic (March 2020-January 2021) was analyzed. Results: There were 3213 live births, 77 miscarriages and 834 undelivered pregnancies. The proportion of pregnancy/foetal loss including stillbirths was six per cent. Five hundred and thirty-four women (13%) were symptomatic, of which 382 (72%) had mild, 112 (21%) had moderate, and 40 (7.5%) had severe disease. The most common complication was preterm delivery (528, 16.3%) and hypertensive disorders in pregnancy (328, 10.1%). A total of 158 (3.8%) pregnant and post-partum women required intensive care, of which 152 (96%) were due to COVID-19 related complications. The overall case fatality rate (CFR) in pregnant and post-partum women with COVID-19 was 0.8 per cent (34/4203). Higher CFR was observed in Pune (9/853, 1.1%), Marathwada (4/351, 1.1%) regions as compared to Vidarbha (9/1155, 0.8%), Mumbai Metropolitan (11/1684, 0.7%), and Khandesh (1/160, 0.6%) regions. Comorbidities of anaemia, tuberculosis and diabetes mellitus were associated with maternal deaths. Interpretation & conclusions: The study demonstrates the adverse outcomes including severe COVID-19 disease, pregnancy loss and maternal death in women with COVID-19 in Maharashtra, India.

Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All".

BACKGROUND: This is the concluding paper of our 11-paper supplement, "Community health workers at the dawn of a new era". METHODS: We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes. RESULTS: CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness. CONCLUSION: A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All.

Magnitude and determinants of obstetric case fatality rate among women with the direct causes of maternal deaths in Ethiopia: a national cross sectional study.

BACKGROUND: In sub-Saharan Africa, maternal death due to direct obstetric complications remains an important health threat for women. A high direct obstetric case fatality rate indicates a poor quality of obstetric care. Therefore, this study was aimed at assessing the magnitude and determinants of the direct obstetric case fatality rate among women admitted to hospitals with direct maternal complications. METHODS: In 2015, the Ethiopian Public Health Institute conducted a national survey about emergency obstetric and newborn care in which data about maternal and neonatal health indicators were collected. Maternal health data from these large national dataset were analysed to address the objective of this study. Descriptive statistics were used to present hospital specific characteristics and the magnitude of direct obstetric case fatality rate. Logistic regression analysis was performed to examine determinants of the magnitude of direct obstetric case fatality rate and the degree of association was measured using an adjusted odds ratio with 95% confidence interval at p < 0.05. RESULTS: Overall, 335,054 deliveries were conducted at hospitals and 68,002 (20.3%) of these women experienced direct obstetric complications. Prolonged labour (23.4%) and hypertensive disorders (11.6%) were the two leading causes of obstetric complications. Among women who experienced direct obstetric complications, 435 died, resulting in the crude direct obstetric case fatality rate of 0.64% (95% CI: 0.58-0.70%). Hypertensive disorders (27.8%) and maternal haemorrhage (23.9%) were the two leading causes of maternal deaths. The direct obstetric case fatality rate varied considerably with the complications that occurred; highest in postpartum haemorrhage (2.88%) followed by ruptured uterus (2.71%). Considerable regional variations observed in the direct obstetric case fatality rate; ranged from 0.27% (95% CI: 0.20-0.37%) at Addis Ababa city to 3.82% (95% CI: 1.42-8.13%) at the Gambella region. Type of hospitals, managing authority and payment required for the service were significantly associated with the magnitude of direct obstetric case fatality rate. CONCLUSIONS: The high direct obstetric case fatality rate is an indication for poor quality of obstetric care. Considerable regional differences occurred with regard to the direct obstetric case fatality rate. Interventions should focus on quality improvement initiatives and equitable resource distribution to tackle the regional disparities.

Burden of hepatitis E virus infection in pregnancy and maternofoetal outcomes: a systematic review and meta-analysis.

BACKGROUND: There is still a dearth of knowledge on the burden of HEV infection in the global population of pregnant women. Therefore, we conducted a systematic review and meta-analysis to estimate the global burden of HEV infection in pregnancy. METHODS: We searched PubMed, Embase, Web of Knowledge, and Global Index Medicus to identify articles published until January 26, 2020. We considered cross-sectional, case-control, and cohort studies reporting the immunoglobulins M HEV seroprevalence in asymptomatic and symptomatic (jaundice or elevated transaminases) pregnant women or investigating the association between HEV infection and maternofoetal outcomes. We used a random-effects model to pool studies. This review was registered with PROSPERO, CRD42018093820. RESULTS: For HEV prevalence estimates, we included 52 studies (11,663 pregnant women). The seroprevalence was 3.5% (95% confidence interval: 1.4-6.4) in asymptomatic women (most of whom from high endemic areas). The prevalence in symptomatic women was 49.6% (42.6-56.7) with data only from HEV high endemic countries. In the multivariable meta-regression model, the prevalence was higher in symptomatic women compared to asymptomatic (adjusted prevalence odds ratio [aPOR]: 1.76; 95%CI: 1.61-1.91) and decreased with increasing year of publication (by 10-year) (aPOR: 0.90; 95%CI: 0.84-0.96). The proportion of HEV vertical transmission was 36.9% (13.3-64.2). Risk of bias was low, moderate and high respectively in 12 (23%), 37 (70%), and 4 studies (7%) addressing HEV prevalence estimation. HEV infection was associated with maternal deaths (pooled OR 7.17; 3.32-15.47), low birth weight (OR: 3.23; 1.71-6.10), small for gestational age (OR: 3.63; 1.25-10.49), preterm < 32 weeks (OR: 4.18; 1.23-14.20), and preterm < 37 weeks (OR: 3.45; 2.32-5.13), stillbirth (OR: 2.61; 1.64-4.14), intrauterine deaths (OR: 3.07; 2.13-4.43), and not with miscarriage (OR: 1.74; 0.77-3.90). All studies which assessed the association between HEV infection and maternofoetal outcomes had a moderate risk of bias. CONCLUSIONS: Findings from this study are suggestive of a high burden of HEV infection in pregnancy in high endemic countries, its association with poor maternofoetal outcomes, and a high rate of vertical transmission. This study supports the need for specific strategies to prevent exposure of pregnant women to HEV infection, especially in high endemic areas.

Perceptions of women of reproductive age towards maternal death in Qaukeni sub-District, Eastern Cape Province, South Africa: A qualitative study.

Maternal mortality is a global problem, particularly in developing countries. This study explored perceptions, knowledge and attitudes of women of reproductive age concerning maternal deaths in Qaukeni Sub-District, Eastern Cape Province, South Africa. This was a community-based qualitative study using using in-depth interviews among women of reproductive age. Data was analyzed using thematic analysis. The study found some of the mothers knew the causes, signs and symptoms of pregnancy as well as danger signs during pregnancy such as haemorrhage, sepsis, high blood pressure and complications of unsupervised home deliveries, while others had little knowledge about these signs and symptoms. The participants indicated that using herbal medications during pregnancy could result to serious complications and even maternal death. Women do not attend antenatal care because of the long distances, absence of clinics, shortage of nurses and doctors; thus, predisposing women to deliver at homes with the assistance of traditional birth attendants, who had limited knowledge related to health issues and the Prevention of Mother- to-Child-Transmission programme. The findings indicated that some women are knowledgeable about the causes of maternal deaths during pregnancy as well as the signs and symptoms of pregnancy. Health education during pregnancy and provision of better resources would help improve the maternal health of women in this rural setting.

Confidential enquiries into maternal deaths in Ondo State, Nigeria - a comparative analysis.

BACKGROUND: Paucity of data on state-wide maternal mortality in Nigeria hampers planning, monitoring and evaluation of the impact of interventions. The Confidential Enquiry into Maternal Deaths in Ondo State was initiated to overcome this problem. This study aimed to compare trends of maternal mortality ratios, causes of deaths, geographical distribution and other associated factors in 12-monthly reports of the Confidential Enquiry into Maternal Deaths in Ondo State. METHODS: Notification forms were distributed throughout the State to focal persons and medical records officers at community and facility levels, respectively. Maternal deaths, as defined in the International Classification of Diseases 10th version, were recorded prospectively over 3 years from 1st June 2012 to 30th May, 2015. Forms were submitted, collated and data analysed by a multidisciplinary review committee. RESULTS: Reported numbers of maternal deaths (and maternal mortality ratios) were 114 (253 per 100,000 births), 89 (192) and 81 (170), respectively per year, indicating a 33% reduction in maternal mortality ratio over the course of the study period. Assuming that the confidential enquiry process was the only intervention at the time aimed at reducing maternal mortality, simple linear regression with a correlation coefficient of 0.9314, showed a relationship though the difference in the values were not statistically significant (95% CI = - 184.55 to 101.55, p = 0.169). Postpartum haemorrhage and eclampsia were the leading causes of deaths. CONCLUSION: There was a trend of reduction in maternal mortality ratio during the period of study with postpartum haemorrhage as the major cause of death. The positive association between the confidential enquiry reports and maternal mortality ratios make us recommend that our model be adopted in other states and at the federal level.

Why rural women do not use primary health centres for pregnancy care: evidence from a qualitative study in Nigeria.

BACKGROUND: While Primary Health Care has been designed to provide universal access to skilled pregnancy care for the prevention of maternal deaths in Nigeria, available evidence suggests that pregnant women in rural communities often do not use Primary Health Care Centres for skilled care. The objective of this study was to investigate the reasons why women do not use PHC for skilled pregnancy care in rural Nigeria. METHODS: Qualitative data were obtained from twenty focus group discussions conducted with women and men in marital union to elicit their perceptions about utilisation of maternal and child health care services in PHC centres. Groups were constituted along the focus of sex and age. The group discussions were tape-recorded, transcribed verbatim and analyzed thematically. RESULTS: The four broad categories of reasons for non-use identified in the study were: 1) accessibility factors - poor roads, difficulty with transportation, long distances, and facility not always open; 2) perceptions relating to poor quality of care, including inadequate drugs and consumables, abusive care by health providers, providers not in sufficient numbers and not always available in the facilities, long waiting times, and inappropriate referrals; 3) high costs of services, which include the inability to pay for services even when costs are not excessive, and the introduction of informal payments by staff; and 4) Other comprising partner support and misinterpretation of signs of pregnancy complications. CONCLUSION: Addressing these factors through adequate budgetary provisions, programs to reduce out-of-pocket expenses for maternal health, adequate staffing and training, innovative methods of transportation and male involvement are critical in efforts to improve rural women's access to skilled pregnancy care in primary health care centres in the country.

Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India.

BACKGROUND: A disproportionately high proportion of maternal deaths (99 percent) in the world occur in low and middle income countries, of which 90 percent is contributed by Sub-Saharan Africa and South Asia. This study uses the effective "Three Delays" model to assess the socio-cultural barriers associated with maternal mortality in West Bengal, India. METHODS: It was a retrospective mixed methods study, which used facility-based as well as community-based approaches to explore factors associated with maternal deaths. We reviewed 317 maternal death cases wherein a verbal autopsy technique was applied on 40 cases. The Chi-square test (χ2) and multivariable logistic regression model were employed to accomplish the study objectives. RESULTS: The delay in seeking care (Type 1 delay) was the most significant contributor to maternal deaths (48.6 percent, 154/317). The second major impacting contributor to maternal deaths was the delay in reaching first level health facility (Type 2 delay) (33.8 percent, 107/317), while delay in receiving adequate care at the health facility (Type 3 delay) had a role in 18.9 percent maternal deaths. Women staying at long distance from the health facilities have reported [AOR with 95 % CI; 1.7 (1.11-1.96)] higher type 2 delay as compared to their counterparts. The study also exhibited that the women belonged to Muslim community were 2.5 times and 1.6 times more likely to experience type 1 and 2 delays respectively than Hindu women. The verbal autopsies revealed that the type 1 delay is attributed to the underestimation of the gravity of the complications, cultural belief and customs. Recognition of danger signs, knowledge and attitude towards seeking medical care, arranging transport and financial constraints were the main barriers of delay in seeking care and reaching facility. CONCLUSIONS: The study found that the type-1 and type-2 delays were major contributors of maternal deaths in the study region. Therefore, to prevent the maternal deaths effectively, action will be required in areas like strengthening the functionality of referral networks, expand coverage of healthcare and raising awareness regarding maternal complications and danger signs.

Causes and contributory factors of maternal mortality: evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria.

BACKGROUND: Nigeria still ranks second globally in the number of maternal deaths. Most maternal death reviews in Nigeria are isolated research based reports from a single health facility. This study determined causes and contributory factors of maternal mortality in Ogun statefollowing a periodic State-widematernal and perinatal deaths surveillance and response (MPDSR) review. METHODS: We carried out a retrospective analysis of cases of maternal deaths notified (n = 77) and reviewed (n = 45) in health facilities in Ogun State from 2015 to 2016selected using total sampling method. Using the national MPDSR structured and validated data collection tools or questionnaire, collected data was extracted from existing MPDSR data base, andanalyzed using the Statistical Package for Social Sciences (SPSS) software 20.0. We obtained approval from the State Ministry of Health for this study. RESULTS: Average age at maternal death was 30.8 ± 5.7 years. Haemorrhageand pre-eclampsia or eclampsia account for 43.4 and 36.9% of causes respectively. Leading contributory factors ofmaternal deaths include inadequate human resource for health, delay in seeking care, inadequate equipment, lack of ambulance transportation, and delay in referrals services. 51.1%of the women had antenatal care while a significant proportion of the women were referred from Traditional Births Attendants (TBAs) and mission houses. CONCLUSION: We concluded that many of the contributory factors of maternal mortality could be avoided if preventive measures were taken and adequate care available. MPDSR provides a platform for critical evidence of where the main problems lie, and can provide valuable information on strategies which maternal mortality prevention programs should focus on. The implementation and institutionalization of MPDSR programme is on course in Ogun State. MPDSR is feasible and should be institutionalized in all states of Nigeria. A commitment to act upon the findings of MPDSR is a key prerequisite for success.

Access factors linked to maternal deaths in Lundazi district, Eastern Province of Zambia: a case control study analysing maternal death reviews.

BACKGROUND: Access factors associated with maternal death are important to understand because they are considered to be an essential measure of women's health and indicative of the performance of health care systems in any community globally. This study aimed to analyse the access risk factors linked to maternal deaths in Lundazi district of the Eastern Province of Zambia using secondary data obtained from maternal death reviews and delivery registers. METHODS: This was a case-control study with cases being recorded maternal deaths for Lundazi district (n = 100) while controls were randomly selected Lundazi District Hospital deliveries (n = 300) for the period 2010 to 2015. STATA™ (Stata Corporation, Texas, TX, USA) version 12.0 was used to analyse data. Odds ratio and 95% confidence intervals with associated p-values were used to analyse disparities between cases and controls while bivariate and multivariate regression analyses were done to show associations. RESULTS: The likelihood of experiencing maternal death was 94% less among women who completed their scheduled antenatal care visits than those who did not (OR 0.06, 95% CI = 0.01-0.27, p = < 0.001). Delayed referral associated with maternal deaths and complications were 30% (30) for cases, 12% (37) for controls and 17% (67) for both cases and controls. Long distances, unskilled deliveries were 3%, (15) for both cases and controls with 13% (13) for cases and 1% (2) for controls only. CONCLUSION: Antenatal care is important in screening for pre-existing risk conditions as well as complications in early stages of pregnancy that could impact adversely during pregnancy and childbirth. Delay in seeking health care during pregnancy could be minimised if health services are brought closer to the communities to reduce on distances covered by pregnant women in Lundazi. Maternal education appears to influence antenatal health care utilisation because greater knowledge and understanding of the importance of antenatal care might increase the ability to select most appropriate service. Therefore, there is need for Lundazi District Health Office to scale up interventions that motivate women to make at least four scheduled antenatal care visits during pregnancy as recommended by the World Health Organization.

Maternal death and delays in accessing emergency obstetric care in Mozambique.

BACKGROUND: Despite declining trends maternal mortality remains an important public health issue in Mozambique. The delays to reach an appropriate health facility and receive care faced by woman with pregnancy related complications play an important role in the occurrence of these deaths. This study aims to examine the contribution of the delays in relation to the causes of maternal death in facilities in Mozambique. METHODS: Secondary analysis was performed on data from a national assessment on maternal and neonatal health that included in-depth maternal death reviews, using patient files and facility records with the most comprehensive information available. Statistical models were used to assess the association between delay to reach the health facility that provides emergency obstetric care (delay type II) and delay in receiving appropriate care once reaching the health facility providing emergency obstetric care (delay type III) and the cause of maternal death within the health facility. RESULTS: Data were available for 712 of 2,198 maternal deaths. Delay type II was observed in 40.4% of maternal deaths and delay type III in 14.2%.and 13.9% had both delays. Women who died of a direct obstetric complication were more likely to have experienced a delay type III than women who died due to indirect causes. Women who experienced delay type II were less likely to have also delay type III and vice versa. CONCLUSIONS: The delays in reaching and receiving appropriate facility-based care for women facing pregnancy related complications in Mozambique contribute significantly to maternal mortality. Securing referral linkages and health facility readiness for rapid and correct patient management are needed to reduce the impact of these delays within the health system.

Empowering members of a rural southern community in Nigeria to plan to take action to prevent maternal mortality: A participatory action research project.

AIMS AND OBJECTIVES: To facilitate the empowerment of members of a rural community to plan to take action to prevent maternal mortality. BACKGROUND: Globally, about 300,000 maternal deaths occur yearly. Sub-Saharan Africa and Southern Asia regions account for almost all the deaths. Within those regions, India and Nigeria account for over a third of the global maternal deaths. Problem of maternal mortality in Nigeria is multifaceted. About 80% of maternal deaths are avoidable, given strategies which include skilled attendants, emergency obstetric care and community mobilisation. In this article, a strategy of community empowerment to plan to take action to prevent maternal mortality is discussed. DESIGN: Participatory action research was used. METHODS: Twelve volunteers were recruited as coresearchers into the study through purposive and snowball sampling who, following an orientation workshop, undertook participatory qualitative data collection with an additional 29 community members. Participatory thematic analysis of the data was undertaken which formed the basis of the plan of action. RESULTS: Community members attributed maternal morbidities and deaths to superstitious causes, delayed referrals by traditional birth attendants, poor transportation and poor resourcing of health facilities. Following critical reflection, actions were planned to empower the people to prevent maternal deaths through community education and advocacy meetings with stakeholders to improve health and transportation infrastructures; training of existing traditional birth attendants in the interim and initiating their collaboration with skilled birth attendants. CONCLUSION: The community is a resource which if mobilised through the process of participatory action research can be empowered to plan to take action in collaboration with skilled birth attendants to prevent maternal mortality. RELEVANCE TO CLINICAL PRACTICE: Interventions to prevent maternal deaths should include community empowerment to have better understanding of their circumstances as well as their collaboration with health professionals.

Midwives' experiences of performing maternal observations and escalating concerns: a focus group study.

BACKGROUND: For the past decade, Maternal Mortality Reports, published in the United Kingdom every three years, have consistently raised concerns about maternal observations in maternity care. The reports identify that observations are not being done, not being completed fully, are not recorded on Early Warning Score systems, and/or are not escalated appropriately. This has resulted in delays in referral, intervention and increases the risk of maternal morbidity or mortality. However there has been little exploration of the possible reasons for non-completion of maternal observations. METHODS: The aim of this study was to explore midwives' experiences of performing maternal observations and escalating concerns in rural and urban maternity settings in the West Midlands of England. A qualitative design involving a series of six focus groups with midwives and Supervisors of Midwives was employed to investigate the facilitators of, and barriers to the completion of maternal observations. RESULTS: Eighteen Midwives and 8 Supervisors of Midwives participated in a total of 6 focus groups. Three key themes emerged from the data: (1) Organisation of Maternal Observations (including delegation of tasks to Midwifery Support Workers, variation in their training, the care model used e.g. one to one care, and staffing issues); (2) Prioritisation of Maternal Observations (including the role of professional judgement and concerns expressed by midwives that they did not feel equipped to care for women with complex clinical needs; and (3) Negotiated Escalation (including the inappropriate response from senior staff to use of Modified Early Warning Score systems, and the emotional impact of escalation). CONCLUSIONS: A number of organisational and cultural barriers exist to the completion of maternal observations and the escalation of concerns. In order to address these the following actions are recommended: standardised training for Midwifery Support Workers, review of training of midwives to ensure it addresses the increasing complexity of the maternal population, identification and agreement regarding the organisation of maternal observations among staff, an emphasis on increasing the priority placed on maternal observations in all clinical settings, and clarification and reinforcement of escalation procedures for both midwives and senior clinicians.

Inadequate programming, insufficient communication and non-compliance with the basic principles of maternal death audits in health districts in Burkina Faso: a qualitative study.

BACKGROUND: Implementation of quality maternal death audits requires good programming, good communication and compliance with core principles. Studies on compliance with core principles in the conduct of maternal death audits (MDAs) exist but were conducted in urban areas, at the 2nd or 3rd level of the healthcare system, in experimental situations, or in a context of skills-building projects or technical platforms with an emphasis on the review of "near miss". This study aims to fill the gap of evidence on the implementation of MDAs in rural settings, at the first level of care and in the routine care situation in Burkina Faso. METHODS: We conducted a multiple-case study, with seven cases (health districts) chosen by contrasted purposive sampling using four criteria: (i) the intra-hospital maternal mortality rates for 2013, (ii) rural versus urban location, (iii) proofs of regular conduct of maternal death audits (MDAs) as per routine health information system, and (iv) the use of district hospital versus regional hospital for reference when the first mentioned does not exist. A review of audit records and structured and semi-structured interviews with staff involved in MDAs were conducted. The survey was conducted from 27 April to 30 May of 2015. RESULTS: The results showed that maternal death audits (MDAs) were irregularly scheduled, mostly driven by critical events. Overall, preparing sessions, communication and the conduct of MDAs were most of the time inadequate. Confidentiality was globally respected during the clinical audit sessions. The principle of "no name, no shame, and no blame" was differently applied and anonymity was rarely preserved. CONCLUSION: Programming, communication, and compliance with the basic principles in the conduct of maternal death audits were inadequate as compared to the national standards. Identifying determinants of such shortcomings may help guide interventions to improve the quality of clinical audits. RESUME: La mise en œuvre d'audits de décès maternels de qualité nécessite une bonne programmation, une bonne communication et le respect des principes fondamentaux. Des études sur le respect des principes fondamentaux existent mais ont été menées dans les zones urbaines, le 2ème ou 3ème niveau du système de santé, dans des situations expérimentales, un contexte de projets de renforcement des compétences ou de plates-formes techniques, en mettant l'accent sur la revue des «near miss¼. Cette étude vise à combler le manque d'information sur la programmation et le respect des principes fondamentaux concernant le milieu rural, le niveau du système de santé qui est. le district sanitaire et la situation de routine au Burkina Faso. MéTHODOLOGIE: Nous avons mené une étude de cas multiple dans 7 établissements de santé sélectionnés par échantillonnage raisonné contrasté selon 4 critères: milieu urbain ou rural, taux de mortalité maternelle dans les établissements de santé en 2013 (les données de l'année 2014 n'étant pas complètes à la rédaction du protocole), la déclaration des audits de décès maternels dans le système de surveillance nationale, le recours ou non par le district choisi à un centre hospitalier régional pour les soins complémentaires de premier niveau (normalement offerts à l'hôpital de district s'il existe). Une revue des dossiers d'audits, ainsi que des entretiens directifs, semi-directifs auprès du personnel impliqué dans les soins de maternité ont été réalisés. L'enquête s'est. déroulée du 27 Avril au 30 Mai 2015. RéSULTATS: Les résultats montrent que les revues des décès maternels ont été irrégulièrement programmées, de façon espacée et très souvent au gré des évènements. La préparation, la conduite des séances et la communication après les séances ont été défaillantes. La confidentialité au sein du groupe d'auditeurs a été respectée tandis que le niveau de respect du principe de « no name, no shame, no blame ¼ a varié d'une structure à une autre. Enfin, l'anonymat a été le moins respecté. CONCLUSION: La programmation, la communication et le respect des principes fondamentaux ont connu des défaillances par rapport aux normes mais de façon variable d'une structure à une autre. L'identification des déterminants de ces insuffisances pourront aider à l'orientation des interventions visant l'amélioration de l'activité des audits de décès maternels au niveau district de santé.

Determinants of use of supervised delivery care under Ghana's fee exemption policy for maternal healthcare: the case of the Central Region.

BACKGROUND: Improving access to supervised and emergency obstetric care resources through fee reduction/exemption maternity care initiatives has been touted as one major strategy to avoiding preventable maternal deaths. Evaluations on the effect of Ghana's fee exemption policy for maternal healthcare have largely focused on how it has influenced health outcomes and patterns of use of supervised care with little attention to understanding the main factors influencing use. This study therefore sought to explore the main individual and health system factors influencing use of delivery care services under the policy initiative in the Central Region. METHODS: A cross-sectional study was conducted using 412 mothers with children aged less than one year in one largely rural and another largely urban districts in the Central Region of Ghana from September to December 2013. Data were collected using a questionnaire survey on the socio-demographic characteristics of mothers, their knowledge and use of care under the fee free policy. Chi-square and Binary Logistic Regression tests were used to evaluate the main determinants of delivery care use under the policy. RESULTS: Out of the 412 mothers interviewed, 268 (65 %) reported having delivered their most recent birth under the fee exemption policy even though awareness about the policy was almost universal 401 (97.3 %) among respondents. Utilization however differed for the two study districts. Respondents in the Cape Coast Metropolis (largely urban) used delivery service more (75.7 %) than those in the largely rural Assin North Municipal area (54.4 %). Binary logistic regression results identified maternal age, parity, religion, place of residence, awareness and knowledge about the fee exemption policy for maternal healthcare as significantly associated with the likelihood of delivery care use under the policy. The likelihood of using supervised delivery care under the policy was lower for mothers aged 20-29 compared to those in the age bracket of 40-49 (Odds ratio (OR) = 0.069, p = 0.003). For their index (last child), mothers who already had 1, 2 or 3 births were more likely to deliver under the policy than those with five or more births. Mothers living in urban areas were 3.79 times more likely to use delivery services under the policy than those living in rural areas (OR = 3.793, p = 0.000). The likelihood of using delivery services under the policy was higher for mothers who were aware and had full knowledge of the total benefit package of the policy (OR = 13.820, p = 0.022 and OR = 2.985, p = 0.001 for awareness and full knowledge respectively). CONCLUSIONS: Delivery service use under the free maternal healthcare policy is relatively low (65 %) when compared with nearly universal awareness (97.3 %) about the policy. Factors influencing delivery service use under the policy operate at both individual and policy implementation levels. Effective interventions to improve delivery service use under the policy should target the underlying individual and health policy implementation factors identified in the study.

Huwa Rog, Parhej, and Desi Dawai: Women's Perceptions of Postpartum Maternal Morbidity and Care in Rajasthan, India.

Although more maternal deaths occur in the postpartum period, this period receives far less attention from the program managers. To understand how the women and their families perceive postpartum health problems, the culturally derived restrictions, and precautions controlling diets and behavior patterns, we conducted a mixed-method study in Rajasthan, India. The study methods included free listing of maternal morbidity conditions, interviews with 81 recently delivered women, case interviews with eight cases of huwa rog (postpartum illness), and interviews with nine key informants. The study showed that huwa rog refers to a broad category of serious postpartum illness, thought to affect women a few weeks to several months after delivery. Prevention of the illness involves a system of precautions referred to as parhej, which includes a distinctive set of "medicinal dietary items" referred to as desi dawai, or "country medicine," and restrictions about mobility and work patterns of a postpartum woman. This cultural framework around the concept of huwa rog and peoples' beliefs about it are of central importance for planning postpartum health interventions, including place of contact and communication messages.