Stillbirth mortality by Robson ten-group classification system: A cross-sectional registry of 80 663 births from 16 hospital in sub-Saharan Africa.

OBJECTIVE: To assess stillbirth mortality by Robson ten-group classification and the usefulness of this approach for understanding trends. DESIGN: Cross-sectional study. SETTING: Prospectively collected perinatal e-registry data from 16 hospitals in Benin, Malawi, Tanzania and Uganda. POPULATION: All women aged 13-49 years who gave birth to a live or stillborn baby weighting >1000 g between July 2021 and December 2022. METHODS: We compared stillbirth risk by Robson ten-group classification, and across countries, and calculated proportional contributions to mortality. MAIN OUTCOME MEASURES: Stillbirth mortality, defined as antepartum and intrapartum stillbirths. RESULTS: We included 80 663 babies born to 78 085 women; 3107 were stillborn. Stillbirth mortality by country were: 7.3% (Benin), 1.9% (Malawi), 1.6% (Tanzania) and 4.9% (Uganda). The largest contributor to stillbirths was Robson group 10 (preterm birth, 28.2%) followed by Robson group 3 (multipara with cephalic term singleton in spontaneous labour, 25.0%). The risk of dying was highest in births complicated by malpresentations, such as nullipara breech (11.0%), multipara breech (16.7%) and transverse/oblique lie (17.9%). CONCLUSIONS: Our findings indicate that group 10 (preterm birth) and group 3 (multipara with cephalic term singleton in spontaneous labour) each contribute to a quarter of stillbirth mortality. High mortality risk was observed in births complicated by malpresentation, such as transverse lie or breech. The high mortality share of group 3 is unexpected, demanding case-by-case investigation. The high mortality rate observed for Robson groups 6-10 hints for a need to intensify actions to improve labour management, and the categorisation may support the regular review of labour progress.

Learning from changes concurrent with implementing a complex and dynamic intervention to improve urban maternal and perinatal health in Dar es Salaam, Tanzania, 2011-2019.

INTRODUCTION: Rapid urbanisation in Dar es Salaam, the main commercial hub in Tanzania, has resulted in congested health facilities, poor quality care, and unacceptably high facility-based maternal and perinatal mortality. Using a participatory approach, the Dar es Salaam regional government in partnership with a non-governmental organisation, Comprehensive Community Based Rehabilitation in Tanzania, implemented a complex, dynamic intervention to improve the quality of care and survival during pregnancy and childbirth. The intervention was rolled out in 22 public health facilities, accounting for 60% of the city's facility births. METHODS: Multiple intervention components addressed gaps across the maternal and perinatal continuum of care (training, infrastructure, routine data quality strengthening and utilisation). Quality of care was measured with the Standards-Based Management and Recognition tool. Temporal trends from 2011 to 2019 in routinely collected, high-quality data on facility utilisation and facility-based maternal and perinatal mortality were analysed. RESULTS: Significant improvements were observed in the 22 health facilities: 41% decongestion in the three most overcrowded hospitals and comparable increase in use of lower level facilities, sixfold increase in quality of care, and overall reductions in facility-based maternal mortality ratio (47%) and stillbirth rate (19%). CONCLUSIONS: This collaborative, multipartner, multilevel real-world implementation, led by the local government, leveraged structures in place to strengthen the urban health system and was sustained through a decade. As depicted in the theory of change, it is highly plausible that this complex intervention with the mediators and confounders contributed to improved distribution of workload, quality of maternity care and survival at birth.

Perceptions and experiences of skilled birth attendants on using a newly developed strap-on electronic fetal heart rate monitor in Tanzania.

BACKGROUND: Regular fetal heart rate monitoring during labor can drastically reduce fresh stillbirths and neonatal mortality through early detection and management of fetal distress. Fetal monitoring in low-resource settings is often inadequate. An electronic strap-on fetal heart rate monitor called Moyo was introduced in Tanzania to improve intrapartum fetal heart rate monitoring. There is limited knowledge about how skilled birth attendants in low-resource settings perceive using new technology in routine labor care. This study aimed to explore the attitude and perceptions of skilled birth attendants using Moyo in Dar es Salaam, Tanzania. METHODS: A qualitative design was used to collect data. Five focus group discussions and 10 semi-structured in-depth interviews were carried out. In total, 28 medical doctors and nurse/midwives participated in the study. The data was analyzed using qualitative content analysis. RESULTS: The participants in the study perceived that the device was a useful tool that made it possible to monitor several laboring women at the same time and to react faster to fetal distress alerts. It was also perceived to improve the care provided to the laboring women. Prior to the introduction of Moyo, the participants described feeling overwhelmed by the high workload, an inability to adequately monitor each laboring woman, and a fear of being blamed for negative fetal outcomes. Challenges related to use of the device included a lack of adherence to routines for use, a lack of clarity about which laboring women should be monitored continuously with the device, and misidentification of maternal heart rate as fetal heart rate. CONCLUSION: The electronic strap-on fetal heart rate monitor, Moyo, was considered to make labor monitoring easier and to reduce stress. The study findings highlight the importance of ensuring that the device's functions, its limitations and its procedures for use are well understood by users.

Use of a criteria-based audit to optimize uptake of cesarean delivery in a low-resource setting.

OBJECTIVE: To evaluate the impact of a criteria-based audit (CBA) of obstructed labor and fetal distress on cesarean delivery and perinatal outcomes. METHODS: A cross-sectional study was performed at a tertiary referral hospital in Tanzania. Data were collected before and after CBA (January 2013-November 2013 and July 2015-June 2016). Outcomes of fetal distress (baseline CBA, n=248; re-audit, n=251) and obstructed labor (baseline CBA, n=260; re-audit n=250) were assessed using a checklist. Additionally, 27 960 parturients were assessed using the Robson classification. RESULTS: Perinatal morbidity and mortality decreased from 42 of 260 (16.2%) to 22 of 250 (8.8%) among patients with obstructed labor after CBA (P=0.012). Cesarean delivery rate decreased for referred term multiparas with induced labor or prelabor cesarean delivery (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.09-0.82). Cesarean delivery rate for preterm pregnancies increased among both referred (OR 1.28, 95% CI 1.02-1.63) and non-referred (OR 2.78, 95% CI 1.98-3.90) groups. Neonatal distress rate decreased for referred term multiparas (OR 0.72, 95% CI 0.56-0.92), referred preterm pregnancies (OR 0.32, 95% CI 0.25-0.39), and non-referred preterm pregnancies (OR 0.26, 95% CI 0.18-0.36). CONCLUSION: Use of CBA reduced poor perinatal outcomes of obstructed labor and increased uptake of cesarean delivery.

Acquiring Knowledge about the Use of a Newly Developed Electronic Fetal Heart Rate Monitor: A Qualitative Study Among Birth Attendants in Tanzania.

In an effort to reduce newborn mortality, a newly developed strap-on electronic fetal heart rate monitor was introduced at several health facilities in Tanzania in 2015. Training sessions were organized to teach staff how to use the device in clinical settings. This study explores skilled birth attendants' perceptions and experiences acquiring and transferring knowledge about the use of the monitor, also called Moyo. Knowledge about this learning process is crucial to further improve training programs and ensure correct, long-term use. Five Focus group discussions (FGDs) were carried out with doctors and nurse-midwives, who were using the monitor in the labor ward at two health facilities in Tanzania. The FGDs were analyzed using qualitative content analysis. The study revealed that the participants experienced the training about the device as useful but inadequate. Due to high turnover, a frequently mentioned challenge was that many of the birth attendants who were responsible for training others, were no longer working in the labor ward. Many participants expressed a need for refresher trainings, more practical exercises and more theory on labor management. The study highlights the need for frequent trainings sessions over time with focus on increasing overall knowledge in labor management to ensure correct use of the monitor over time.

Implementation of a novel continuous fetal Doppler (Moyo) improves quality of intrapartum fetal heart rate monitoring in a resource-limited tertiary hospital in Tanzania: An observational study.

BACKGROUND: Intrapartum Fetal Heart Rate (FHR) monitoring is crucial for the early detection of abnormal FHR, facilitating timely obstetric interventions and thus the potential reduction of adverse perinatal outcomes. We explored midwifery practices of intrapartum FHR monitoring pre and post implementation of a novel continuous automatic Doppler device (the Moyo). METHODOLOGY: A pre/post observational study among low-risk pregnancies at a tertiary hospital was conducted from March to December 2016. In the pre-implementation period, intermittent monitoring was conducted with a Pinard stethoscope (March to June 2016, n = 1640 women). In the post-implementation period, Moyo was used for continuous FHR monitoring (July-December 2016, n = 2442 women). The primary outcome was detection of abnormal FHR defined as absent, FHR<120or FHR>160bpm. The secondary outcomes were rates of assessment/documentation of FHR, obstetric time intervals and intrauterine resuscitations. Chi-square test, Fishers exact test, t-test and Mann-Whitney U test were used in bivariate analysis whereas binary and multinomial logistic regression were used for multivariate. RESULTS: Moyo use was associated with greater detection of abnormal FHR (8.0%) compared with Pinard (1.6%) (p<0.001). There were higher rates of non-assessment/documentation of FHR pre- (45.7%) compared to post-implementation (2.2%) (p<0.001). At pre-implementation, 8% of deliveries had FHR documented as often as ≤ 60 minutes, compared to 51% post-implementation (p<0.001). Implementation of continuous FHR monitoring was associated with a shorter time interval from the last FHR assessment to delivery i.e. median (IQR) of 60 (30,100) to 45 (21,85) minutes (p<0.001); and shorter time interval between each FHR assessment i.e. from 150 (86,299) minutes to 60 (41,86) minutes (p<0.001). Caesarean section rates increased from 2.6 to 5.4%, and vacuum deliveries from 2.2 to 5.8% (both p<0.001). Perinatal outcomes i.e. fresh stillbirths and early neonatal deaths were similar between time periods. The study was limited by both lack of randomization and involvement of low-risk pregnant women with fewer adverse perinatal outcomes than would be expected in a high-risk population. CONCLUSION: Implementation of the Moyo device, which continuously measures FHR, was associated with improved quality in FHR monitoring practices and the detection of abnormal FHR. These improvements led to more frequent and timely obstetric responses. Follow-up studies in a high-risk population focused on a more targeted description of the FHR abnormalities and the impact of intrauterine resuscitation is a critical next step in determining the effect on reducing perinatal mortality.

A care bundle including antenatal corticosteroids reduces preterm infant mortality in Tanzania a low resource country.

BACKGROUND: Preterm neonatal mortality (NM) has remained high and unchanged for many years in Tanzania, a resource-limited country. Major causes of mortality include birth asphyxia, respiratory insufficiency and infections. Antenatal corticosteroids (ACS) have been shown to significantly reduce mortality in developed countries. There is inconsistent use of ACS in Tanzania. OBJECTIVE: To determine whether implementation of a care bundle that includes ACS, maternal antibiotics (MA), neonatal antibiotics (NA) and avoidance of moderate hypothermia (temperature < 36°C) targeting infants of estimated gestational age (EGA) 28 to 34 6/7 weeks would reduce NM (< 7 days) by 35%. METHODS: A Pre (September 2014 to May 2015) and Post (June 2015 to June 2017) Implementation strategy was used and introduced at three University-affiliated and one District Hospital. Dexamethasone, as the ACS, was added to the national formulary in May 2015, facilitating its free use down to the district level. FINDINGS: NM was reduced 26% from 166 to 122/1000 livebirths (P = 0.005) and fresh stillbirths (FSB) 33% from 162/1000 to 111/1000 (p = 0.0002) Pre versus Post Implementation. Medications including combinations increased significantly at all sites (p<0.0001). By logistic regression, combinations of ACS, maternal and NA (odds ratio (OR) 0.33), ACS and NA (OR 0.30) versus no treatment were significantly associated with reduced NM. NM significantly decreased per 250g birthweight increase (OR 0.59), and per one week increase in EGA (OR 0.87). Moderate hypothermia declined pre versus post implementation (p<0.0001) and was two-fold more common in infants who died versus survivors. INTERPRETATION: A low-cost care bundle, ~$6 per patient, was associated with a significant reduction in NM and FSB rates. The former presumably by reducing respiratory morbidity with ACS and minimizing infections with antibiotics. If these findings can be replicated in other resource-limited settings, the potential for further reduction of <5 year mortality rates becomes enormous.

"I Was Relieved to Know That My Baby Was Safe": Women's Attitudes and Perceptions on Using a New Electronic Fetal Heart Rate Monitor during Labor in Tanzania.

To increase labor monitoring and prevent neonatal morbidity and mortality, a new wireless, strap-on electronic fetal heart rate monitor called Moyo was introduced in Tanzania in 2016. As part of the ongoing evaluation of the introduction of the monitor, the aim of this study was to explore the attitudes and perceptions of women who had worn the monitor continuously during their most recent delivery and perceptions about how it affected care. This knowledge is important to identify barriers towards adaptation in order to introduce new technology more effectively. We carried out 20 semi-structured individual interviews post-labor at two hospitals in Tanzania. A thematic content analysis was used to analyze the data. Our results indicated that the use of the monitor positively affected the women's birth experience. It provided much-needed reassurance about the wellbeing of the child. The women considered that wearing Moyo improved care due to an increase in communication and attention from birth attendants. However, the women did not fully understand the purpose and function of the device and overestimated its capabilities. This highlights the need to improve how and when information is conveyed to women in labor.

Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania.

OBJECTIVE: In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting. METHODS: A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit. RESULTS: Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01). CONCLUSION: A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.

Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania.

BACKGROUND: In Tanzania, substandard intrapartum management of foetal distress contributes to a third of perinatal deaths, and the majority are term deliveries. We conducted a criteria-based audit with feedback to determine whether standards of diagnosis and management of foetal distress would be improved in a low-resource setting. METHODS: During 2013-2015, a criteria-based audit was performed at the national referral hospital in Dar es Salaam. Case files of deliveries with a diagnosis of foetal distress were identified and audited. Two registered nurses under supervision of a nurse midwife, a specialist obstetrician and a consultant obstetrician, reviewed the case files. Criteria for standard diagnosis and management of foetal distress were developed based on international and national guidelines, and literature reviews, and then, stepwise applied, in an audit cycle. During the baseline audit, substandard care was identified, and recommendations for improvement of care were proposed and implemented. The effect of the implementations was assessed by the differences in percentage of standard diagnosis and management between the baseline and re-audit, using Chi-square test or Fisher's exact test, when appropriate. RESULTS: In the baseline audit and re-audit, 248 and 251 deliveries with a diagnosis of foetal distress were identified and audited, respectively. The standard of diagnosis increased significantly from 52 to 68 % (p < 0.001). Standards of management improved tenfold from 0.8 to 8.8 % (p < 0.001). Improved foetal heartbeat monitoring using a Fetal Doppler was the major improvement in diagnoses, while change of position of the mother and reduced time interval from decision to perform caesarean section to delivery were the major improvements in management (all p < 0.001). Percentage of cases with substandard diagnosis and management was significantly reduced in both referred public and non-referred private patients (all p ≤ 0.01) but not in non-referred public and referred private patients. CONCLUSION: The criteria-based audit was able to detect substandard diagnosis and management of foetal distress and improved care using feedback and available resources.

The effects of previous cesarean deliveries on severe maternal and adverse perinatal outcomes at a university hospital in Tanzania.

OBJECTIVE: To investigate if multiparous individuals who had undergone a previous cesarean delivery experienced an increased risk of severe maternal outcomes or adverse perinatal outcomes compared with multiparous individuals who had undergone previous vaginal deliveries. METHODS: An analytical cross-sectional study at a university hospital in Dar es Salaam, Tanzania, enrolled multiparous participants of at least 28weeks of pregnancy between February 1 and June 30, 2012 . Data were collected from patients' medical records and the hospital's obstetric database. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare outcomes among patients who had or had not undergone previous cesarean deliveries. RESULTS: A total of 2478 patients were enrolled. A previous cesarean delivery resulted in no increase in the risk of severe maternal outcomes (OR 0.86, 95% CI 0.58-1.26; P=0.46), and decreased risk of stillbirth (OR 0.42, 95% CI 0.29-0.62, P<0.001), and intrapartum stillbirth and neonatal distress (OR 0.58, 95% CI 0.38-0.87, P=0.007). CONCLUSION: Previous cesarean delivery was not a risk factor for severe maternal outcomes or adverse perinatal outcomes. The present study was conducted at a referral institution, where individuals with previous cesarean deliveries may constitute a healthy group. Additionally, there could be differences between the study groups in terms of healthcare-seeking behavior, referral mechanisms, intrapartum monitoring, and clinical decision making.

Fear, blame and transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting.

In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5-6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings in the discussion of how transparency and auditing can induce behavioral change and have unintended effects. Caregivers had divergent opinions on whether the hospital's CS rate was a problem or not, but most thought that there was an overuse of CS. All caregivers rationalized the high CS rate by referring to circumstances outside their control. In private practice, some stated they were affected by the economic compensation for CS, while others argued that unnecessary CSs were due to maternal demand. Residents often missed support from their senior colleagues when making decisions, and felt that midwives pushed them to perform CSs. Many caregivers stated that their fear of blame from colleagues and management in case of poor outcomes made them advocate for, or perform, CSs on doubtful indications. In order to lower CS rates, caregivers must acknowledge their roles as decision-makers, and strive to minimize unnecessary CSs. Although auditing and transparency are important to improve patient safety, they must be used with sensitivity regarding any unintended or counterproductive effects they might have.

'What about the mother?' Women's and caregivers' perspectives on caesarean birth in a low-resource setting with rising caesarean section rates.

OBJECTIVE: in light of the rising caesarean section rates in many developing countries, we sought to explore women's and caregivers' experiences, perceptions, attitudes, and beliefs in relation to caesarean section. DESIGN: qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis. SETTING: a public university hospital in Dar es Salaam, Tanzania. PARTICIPANTS: we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each. Women had undergone a caesarean section within two months preceding the interview and were interviewed in their homes. Caregivers were consultants, specialists, residents, and midwives. FINDINGS: both women and caregivers preferred vaginal birth, but caregivers also had a favourable attitude towards caesarean section. While caregivers emphasised their efforts to counsel women on caesarean section, women had often reacted with fear and shock to the caesarean section decision and perceived that there was a lack of indications. Although caesarean section was perceived as involving higher maternal risks than vaginal birth, both women and caregivers justified these risks by the need to 'secure' a healthy baby. Religious beliefs and community members seemed to influence women's caesarean section attitudes, which often made caregivers frustrated as it diminished their role as decision-makers. Undergoing caesarean section had negative socio-economic consequences for women and their families; however, caregivers seldom took these factors into account when making decisions. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: we raise a concern that women and caregivers might overlook maternal risks with caesarean section for the benefit of the baby, a shift in focus that can have serious consequences on women's health in low-resource settings. Caregivers need to reflect on how they counsel women on caesarean section, as many women perceived a lack of indication for their operations. Supportive attendance by a relative during birth and more comprehensive antenatal care counselling about caesarean section indications and complications might enhance women's autonomy and birth preparedness.

Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania.

BACKGROUND: The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications. METHODS: We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital in Dar es Salaam, Tanzania. Cases were assessed individually to determine their association with CS. Main outcome measures included MNM ratio; maternal mortality ratio; proportion of MNM and death associated with CS complications; and the risk for such outcomes per 1,000 operations. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was calculated. RESULTS: We identified 467 MNM events and 77 maternal deaths. The MNM ratio was 36 per 1,000 live births (95% CI 33-39) and the maternal mortality ratio was 587 per 100,000 live births (95% CI 460-730). Major causes were eclampsia and postpartum haemorrhage, but we also detected nine MNM events and five deaths from iatrogenic complications. CS complications accounted for 7.9% (95% CI 5.6-11) of the MNM events and 13% (95% CI 6.4-23) of the maternal deaths. The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital (22/1,000 operations, 95% CI 12-37) compared to the university hospital (7.0/1,000 operations, 95% CI 3.8-12) (risk ratio 3.2, 95% CI 1.5-6.6). CONCLUSIONS: The occurrence of MNM and death at the two hospitals was high, and many cases were associated with CS complications. The maternal risks of CS in low-resource settings must not be overlooked, and measures should be taken to avoid unnecessary CSs. More comprehensive training of staff, improved postoperative surveillance, and a more even distribution of resources within the health care system might reduce the risks of CS.

Grand multiparity: is it still a risk in pregnancy?

BACKGROUND: The association of grand multiparity and poor pregnancy outcome has not been consistent for decades. Classifying grand multiparous women as a high-risk group without clear evidence of a consistent association with adverse outcomes can lead to socioeconomic burdens to the mother, family and health systems. We compared the maternal and perinatal complications among grand multiparous and other multiparous women in Dar es Salaam in Tanzania. METHODS: A cross-sectional study was undertaken at Muhimbili National Hospital (MNH). A standard questionnaire enquired the following variables: demographic characteristics, antenatal profile and detected obstetric risk factors as well as maternal and neonatal risk factors. Predictors of adverse outcomes in relation to grand multiparous women were assessed at p = 0.05. RESULTS: Grand multiparas had twice the likelihood of malpresentation and a threefold higher prevalence of meconium-stained liquor and placenta previa compared with lower-parity women even when adjusted for age. Neonates delivered by grand multiparous women (12.1%) were at three-time greater risk of a low Apgar score compared with lower-parity women (5.4%) (odds ratio (OR), 2.9; 95% confidence interval (CI), 1.5-5.0). Grand multiparity and low birth weight were independently associated with a low Apgar score (OR, 2.4; 95%, CI 1.4-4.2 for GM; OR, 4.2; 95% CI, 2.3-7.8) for low birth weight. CONCLUSION: Grand multiparity remains a risk in pregnancy and is associated with an increased prevalence of maternal and neonatal complications (malpresentation, meconium-stained liquor, placenta previa and a low Apgar score) compared with other multiparous women who delivered at Muhimbili National Hospital.

Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania.

BACKGROUND: Rising caesarean section (CS) rates have been observed worldwide in recent decades. This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country. METHODS: We conducted a hospital-based panel study at Muhimbili National Hospital, Dar es Salaam, Tanzania. All deliveries between 2000 and 2011 with gestational age ≥ 28 weeks were included in the study. The 12 years were divided into four periods: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. Main outcome measures included CS rate, relative size of obstetric groups, contribution to overall CS rate, perinatal mortality ratio, neonatal distress, and maternal mortality ratio. Time trends were analysed within the ten Robson groups, based on maternal and obstetric characteristics. We applied the χ2 test for trend to determine whether changes were statistically significant. Odds ratios of CS were evaluated using multivariate logistic regression, accounting for maternal age, referral status, and private healthcare insurance. RESULTS: We included 137,094 deliveries. The total CS rate rose from 19% to 49%, involving nine out of ten groups. Multipara without previous CS with single, cephalic pregnancies in spontaneous labour had a CS rate of 33% in 2009 to 2011. Adjusted analysis explained some of the increase. Perinatal mortality and neonatal distress decreased in multiple pregnancies (p < 0.001 and p = 0.003) and nullipara with breech pregnancies (p < 0.001 and p = 0.024). Although not statistically significant, there was an increase in perinatal mortality (p = 0.381) and neonatal distress (p = 0.171) among multipara with single cephalic pregnancies in spontaneous labour. The maternal mortality ratio increased from 463/100, 000 live births in 2000 to 2002 to 650/100, 000 live births in 2009 to 2011 (p = 0.031). CONCLUSION: The high CS rate among low-risk groups suggests that many CSs might have been performed on questionable indications. Such a trend may result in even higher CS rates in the future. While CS can improve perinatal outcomes, it does not necessarily do so if performed routinely in low-risk groups.

Large neurofibroma of the labia majora: A case report.

Neurofibromatosis is an autosomal dominant progressive disorder with an incidence of approximately 1 in 3000 live births. Its recognized features include hyper-pigmented skin lesions (cafe-au-lait spots), neurofibromas, iris hamartomas, macrocephaly, central nervous system tumours, defects of the skull and facial bones, and vascular lesions. Involvement of the external genitalia is extremely unusual. This report describes a case of a vulva neurofibroma in a 15-years old teenage girl with no history of trauma or features of Von Recklinghausen's disease. Treatment involved total excision of the tumour under spinal anaesthesia. The diagnosis of neurofibroma was confirmed by histological examination which showed spindle shaped cells with wavy nuclei arranged in a loose myxomatous stroma. No further treatment was offered but the patient was counselled on the possibility of recurrence. She was seen one month after excision and there were no signs of recurrence.

Management of congenital absence of the cervix: A case report.

Cervical agenesis or dysgenesis is an extremely rare congenital anomaly. Conservative surgical approach to these patients involves uterovaginal anastomosis, cervical canalization, and cervical reconstruction. In failed conservative surgery, total hysterectomy is the treatment of choice. Success of reconstructive surgery depends on the amount of cervical tissue available. Hence, congenital absence of the cervix is a complex surgical problem and should be dealt with after thorough evaluation. We report an 18-year-old girl presented with primary amenorrhoea and cyclic monthly abdominal pain. Initial attempted reconstructive surgery failed and hysterectomy was done. At laparotomy, there was only fibrous tissue and no cervical tissue at all. No findings related to endometriosis were observed. The uterus was removed and sectioning the fibrous tissue level of the blind vaginal cuff. Gross tissue examination showed a non communicating uterine cavity, filled with menstrual blood of about 200 ms and a diffusely hypertrophy myometrium. The cervix was absent. Microscopically, there was no cervical tissue in the specimen; the uterine muscles had evidence of adenomyosis. In conclusion, recanalization and cervical reconstruction procedures may be performed on carefully selected patients, consideration should be directed to the presence of adequate cervical stroma absence of which warrants hysterectomy.

Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania.

BACKGROUND: Perinatal death is a devastating experience for the mother and of concern in clinical practice. Regular perinatal audit may identify suboptimal care related to perinatal deaths and thus appropriate measures for its reduction. The aim of this study was to perform a qualitative perinatal audit of intrapartum and early neonatal deaths and propose means of reducing the perinatal mortality rate (PMR). METHODS: From 1st August, 2007 to 31st December, 2007 we conducted an audit of perinatal deaths (n = 133) with birth weight 1500 g or more at Muhimbili National Hospital (MNH). The audit was done by three obstetricians, two external and one internal auditors. Each auditor independently evaluated the cases narratives. Suboptimal factors were identified in the antepartum, intrapartum and early neonatal period and classified into three levels of delay (community, infrastructure and health care). The contribution of each suboptimal factor to adverse perinatal outcome was identified and the case graded according to possible avoidability. Degree of agreement between auditors was assessed by the kappa coefficient. RESULTS: The PMR was 92 per 1000 total births. Suboptimal factors were identified in 80% of audited cases and half of suboptimal factors were found to be the likely cause of adverse perinatal outcome and were preventable. Poor foetal heart monitoring during labour was indirectly associated with over 40% of perinatal death. There was a poor to fair agreement between external and internal auditors. CONCLUSION: There are significant areas of care that need improvement. Poor monitoring during labour was a major cause of avoidable perinatal mortality. This type of audit was a good starting point for quality assurance at MNH. Regular perinatal audits to identify avoidable causes of perinatal deaths with feed back to the staff may be a useful strategy to reduce perinatal mortality.

Impact of change in maternal age composition on the incidence of Caesarean section and low birth weight: analysis of delivery records at a tertiary hospital in Tanzania, 1999-2005.

BACKGROUND: Previous studies on change in maternal age composition in Tanzania do not indicate its impact on adverse pregnancy outcomes. We sought to establish temporal changes in maternal age composition and their impact on annual Caesarean section (CS) and low birth weight deliveries (LBWT) at Muhimbili National Hospital in Tanzania. METHODS: We conducted data analysis of 91,699 singleton deliveries that took place in the hospital between 1999 and 2005. The data were extracted from the obstetric data base. Annual proportions of individual age groups were calculated and their trends over the years studied. Multiple logistic analyses were conducted to ascertain trends in the risks of CS and LBWT. The impact of age composition changes on CS and LBWT was estimated by calculating annual numbers of these outcomes with and without the major changes in age composition, all others remaining equal. In all statistics, a p value < 0.05 was considered significant. RESULTS: The proportion of teenage mothers (12-19 years) progressively decreased over time while that of 30-34 years age group increased. From 1999, the risk of Caesarean delivery increased steadily to a maximum in 2005 [adjusted OR = 1.7; 95%CI (1.6-1.8)] whereas that of LBWT declined to a minimum in 2005 (adjusted OR = 0.76; 95% CI (0.71-0.82). The current major changes in age trend were responsible for shifts in the number of CS of up to206 cases per year. Likewise, the shift in LBWT was up to 158 cases per year, but the 30-34 years age group had no impact on this. CONCLUSION: The population of mothers giving birth at MNH is progressively becoming older with substantial impact on the incidence of CS and LBWT. Further research is needed to estimate the health cost implications of this change.