Outcome of induction of labour at 41 weeks with foley catheter in midwifery-led care.

OBJECTIVE: Assess the outcome of induction of labour (IOL) with a Foley catheter in pregnancies at 41 weeks in midwifery-led care setting compared to consultant-led care setting. DESIGN: Mixed-methods cohort study at a midwifery - hospital partnership in Amsterdam, the Netherlands. SETTING AND PARTICIPANTS: Prospectively, women undergoing IOL in midwifery-led care were recruited at a secondary hospital. This group was compared to a retrospective cohort, in which IOL was exclusively performed under consultant-led care. MEASUREMENTS AND FINDINGS: We compared 320 women whose induction started in midwifery-led care to a historical cohort of 320 women induced for the same reason under consultant-led care. Both groups exhibited similar rates of spontaneous vaginal births (64.2 %vs62.5 %). Caesarean section and assisted vaginal birth rates did not significantly differ. Maternal adverse outcomes were comparable, while neonatal adverse outcomes were significantly higher in the midwifery-led care group (8.1 %vs3.8 %; OR 2.27, 95 % CI 1.12-4.58). The use of pain relief was significantly lower in midwife-led care (65.3 %vs75.3 %; OR 0.62, 95 % CI 0.44-0.87). 20.6 % of births occurred in midwife-led care. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: In this single-centre study, spontaneous vaginal birth rates following IOL with a Foley catheter were similar between midwife- and consultant-led care. However, the midwife-led group showed a higher risk of adverse neonatal outcomes, mainly early onset neonatal sepsis, with a minority eventually delivering under midwife-led care. Implications highlight the need for broader research, validation across diverse settings and exploration of patient and healthcare worker perspectives to refine the evolving midwifery-led care model.

The multidimensional impact of maternal near-miss on the lives of women in Zanzibar, Tanzania: a prospective, 1-year follow-up study.

BACKGROUND: Severe maternal morbidity has been shown to have specific, long-term effects on health and wellbeing, such as daily functioning and mental health. OBJECTIVE: This study aimed to multidimensionally assess the long-term impact of maternal near-miss complications in Zanzibar. STUDY DESIGN: A prospective cohort study was conducted in Zanzibar's referral hospital. Women with maternal near-miss complications were matched with controls. At 3, 6, and 12 months after hospital discharge, history was taken, blood pressure and haemoglobin levels were measured, and multiple validated questionnaires (WHOQOL-BREF, WHODAS2.0, Patient Health Questionnaire-9, Harvard Trauma Questionnaire-16) were administered assessing experienced quality of life and disability, and screening for depression and posttraumatic stress disorder. RESULTS: We included 223 women after maternal near-miss complications and 213 women controls. There was a high prevalence of hypertension at 6 and 12 months in both groups and significantly higher after a near-miss. The proportion of women with low quality of life, disability, depression, or posttraumatic stress disorder was not significantly different between the 2 groups. A poor outcome for at least 1 of these 3 health domains was more prevalent after a near-miss complication. CONCLUSION: In Zanzibar, women after maternal near-miss complications report similar but slower recovery to control participants in the assessed dimensions. Adaptation of perceptions on and coping mechanisms with daily reality might partly explain this. Hypertension has a high prevalence after childbirth and should be treated adequately to prevent recurrent obstetrical and cardiovascular complications. Blood pressure follow-up for all women who delivered at Mnazi Mmoja Hospital seemed justified.

Too busy to care? Analysing the impact of system-related factors on maternal mortality in Zanzibar's Referral Hospital.

This study analyses the contribution of system-related factors to maternal mortality in the low-resource setting of Mnazi Mmoja Hospital in Zanzibar, Tanzania. It is a retrospective cohort study including all maternal deaths (MD, n = 139) and maternal near-misses (MNM, n = 122) in Mnazi Mmoja Hospital with sufficient documentation during 2015 to 2018 (MD) and 2017 to 2018 (MNM). The number of admissions and surgical interventions per health care provider on the day of admission and the number of times vital signs were monitored per day were compared between MNM and MD cases using logistic regression. The mean number of times vital signs were monitored per day was associated with reduced odds of mortality (aOR 0.75, 95% CI 0.64-0.89), after adjustment for confounding factors such as severity of illness. The numbers of admissions or surgical procedures per health care provider were not associated with mortality. Concluding, the degree of monitoring of patients with life-threatening complications of pregnancy or childbirth is associated with the risk of mortality independent of the degree of severity. Preventing maternal mortality requires going beyond availability of essential interventions to tackle system-related factors that have a direct impact on the capacity to provide comprehensive care.Impact StatementWhat is already known on this subject? Root cause analyses of maternal deaths have identified many system-related factors, such as availability of health care providers, adequate training, and motivation to sustain high intensity monitoring (Madzimbamuto et al. 2014; Mahmood et al. 2018).What do the results of this study add? This is the first study to attempt to quantify the contribution of these system-related factors by comparing cases of maternal death with cases of maternal near-miss. We show that the degree of monitoring of patients with life-threatening complications is associated with the odds of mortality independent of the degree of severity. Even though this relation should not be regarded as causative, monitoring of vital signs can be seen as reflective of many system-related factors which hamper or facilitate comprehensive care.What are the implications of these findings for clinical practice and/or further research? This study helps increase general understanding of the factors leading to progression from severe disease to death in a high-volume low-income setting.

Journey to facility birth in Zanzibar: a questionnaire-based cohort study of patients' perspectives on preparedness, access and quality of care.

INTRODUCTION: Tackling substandard maternity care in health facilities requires engaging women's perspectives in strategies to improve outcomes. This study aims to provide insights in the perspectives of women with severe maternal morbidity on preparedness, access and quality of care in Zanzibar's referral hospital. METHODS: In a prospective cohort from April 2017 to December 2018, we performed semistructured interviews with women who experienced maternal near-miss complications and matched controls. These focused on sociodemographic and obstetric characteristics, perceived accessibility to and quality of facility care with 15 domains, scored on a one-to-five scale. Participants' comments and answers to open questions were employed to illustrate quantitative outcomes. Zanzibar's Medical Research and Ethics Committee approved the study (ZAMREC/0002/JUN/17). RESULTS: We included 174 cases and 151 controls. Compared with controls, patients with a near-miss had less formal education (p=0.049), perceived their wealth as poor (p=0.002) and had a stillbirth more often (p<0.001). Many experienced a delay in deciding to seek care. More than controls, near-miss patients experienced barriers in reaching care (p=0.049), often of financial nature (13.8% vs 4.0%). Quality of care was perceived as high, with means above 3 out of 5, in 14 out of 15 domains. One-fifth had an overall suboptimal experience, mostly regarding informed choice and supplies availability. Additional comments were expressed by a minority of participants. CONCLUSION: Most patients promptly sought, accessed and received maternity care in Zanzibar's referral hospital. A minority experienced barriers, mostly financial, in reaching care and more so among patients with near-miss complications. Quality of facility care was generally highly rated. However, some reported insightful critical perceptions. This study highlights the impact of sociodemographic differences on health, the value of involving patients in decisions regarding maternity care and the need to ensure availability of medical supplies, all which will contribute to improved maternal well-being.

Retrospective validation study of miniPIERS prediction model in Zanzibar.

OBJECTIVE: To perform a retrospective external validation of miniPIERS in Zanzibar's referral hospital. METHODS: From February to December 2017, data were collected retrospectively on all cases of hypertensive disorders of pregnancy (HDP) admitted to Mnazi Mmoja Hospital, Zanzibar, Tanzania. The primary outcome was the predictive performance of miniPIERS by examining measures of discrimination, calibration, and stratification accuracy. The secondary outcome was the applicability of miniPIERS within the referral hospital setting. RESULTS: During this period, 2218 of 13 395 (21%) patients were identified with HDP, of whom 594 met the inclusion criteria. Sixty per cent of patients with adverse outcomes were excluded because they had experienced one of the adverse outcomes before admission. The discriminative ability of miniPIERS was inaccurate. It was not likely to aid risk stratification because of low sensitivity and low positive predictive value. The model showed fair discrimination in HDP before 34 weeks of gestation (area under the receiver operating characteristics curve 0.72, 95% confidence interval 0.63-0.82). CONCLUSIONS: The benefit of miniPIERS appeared to be limited, although clinical conditions make any validation challenging. Its application for risk stratification in preterm pregnancies should be further investigated.

Mental Health and Quality of Life of Women One Year after Maternal Near-Miss in Low and Middle-Income Countries: The Case of Zanzibar, Tanzania.

Women who experienced a maternal near-miss are at risk of mental health complications and lower quality of life, but long-term consequences are largely unknown. The aim of this study is to assess whether mental health symptoms and quality of life change over time and to examine associations with risk factors among post-partum women. In this cohort study, women with maternal near-miss were matched to women without or with mild complications at Mnazi Mmoja Hospital in Zanzibar. Depressive and post-traumatic stress disorder symptoms, and quality of life were measured at three, six, and twelve-months follow-up. A linear mixed-effects model was used for data analysis. Postpartum women in Zanzibar reported low levels of depressive and post-traumatic stress disorder symptoms. While depressive symptoms and quality of life trajectories were similar among women with and without maternal near-miss, differences for trajectories of post-traumatic stress disorder symptoms and physical quality of life were found. Social support, perinatal loss, and intercurrent illness were strongly associated with both depressive symptoms and quality of life in this group of Islamic women. These findings suggest that social support, embedded in the cultural context, should be considered in helping women cope with mental health issues in the aftermath of severe maternal complications.

"I lost my happiness, I felt half dead and half alive" - a qualitative study of the long-term aftermath of obstetric near-miss in the urban district of Zanzibar, Tanzania.

BACKGROUND: This study aims to explore the stories of three women from Zanzibar, Tanzania, who survived life-threatening obstetric complications. Their narratives will increase understanding of the individual and community-level burden masked behind the statistics of maternal morbidity and mortality in Tanzania. In line with a recent systematic review of women-centred, qualitative maternal morbidity research, this study will contribute to guidance of local and global maternal health agendas. METHODS: This two-phased qualitative study was conducted in July-August 2017 and July-August 2018, and involved three key informants, who were recruited from a maternal near-miss cohort in May 2017 in Mnazi Mmoja Hospital, Zanzibar. The used methods were participant observation, interviews (informal, unstructured and semi-structured), participatory methods and focus group discussions. Data analysis relied primarily on grounded theory, leading to a theoretical model, which was validated repeatedly by the informants and within the study team. The findings were then positioned in the existing literature. Approval was granted by Zanzibar's Medical Ethical Research Committee (reference number: ZAMREC/0002/JUN/17). RESULTS: The impact of severe maternal morbidity was found to be multi-dimensional and to extend beyond hospital discharge and thus institutionalized care. Four key areas impacted by maternal morbidities emerged, namely (1) social, (2) sexual and reproductive, (3) psychological, and (4) economic well-being. CONCLUSIONS: This study showed how three women's lives and livelihoods were profoundly impacted by the severe obstetric complications they had survived, even up to 16 months later. These impacts took a toll on their physical, social, economic, sexual and psychological well-being, and affected family and community members alike. These findings advocate for a holistic, dignified, patient value-based approach to the necessary improvement of maternal health care in low-income settings. Furthermore, it emphasizes the need for strategies to be directed not only towards quality of care during pregnancy and delivery, but also towards support after obstetric complications.

Validity of WHO's near-miss approach in a high maternal mortality setting.

OBJECTIVE: To evaluate the validity of WHO's near-miss approach in a low-resource, high maternal mortality setting. DESIGN: Prospective cohort study. SETTING: Mnazi Mmoja Hospital, the main referral hospital of Zanzibar, Tanzania, from 1 April 2017 until 31 December 2018. POPULATION: All women, pregnant or until 42 days after the end of pregnancy, admitted at Mnazi Mmoja Hospital, the tertiary referral hospital in Zanzibar. METHODS: Cases of maternal morbidity and mortality were evaluated according to WHO's near-miss approach. The approach's performance was determined by calculating its accuracy through sensitivity, specificity and positive and negative likelihood ratios. The approach's validity was assessed with Pearson's correlation coefficient between the number of organ dysfunction markers and risk of mortality. MAIN OUTCOMES MEASURES: Correlation between number of organ dysfunction markers and risk of mortality, sensitivity and specificity. RESULTS: 26,842 women were included. There were 335 with a severe maternal outcome: 256 maternal near-miss cases and 79 maternal deaths. No signs of organ dysfunction were documented in only 4 of the 79 cases of maternal death. The number of organ dysfunction markers was highly correlated to the risk of mortality with Pearson's correlation coefficient of 0.89. CONCLUSIONS: WHO's near-miss approach adequately identifies women at high risk of maternal mortality in Zanzibar's referral hospital. There is a strong correlation between the number of markers of organ dysfunction and mortality risk.

Predicting resource-dependent maternal health outcomes at a referral hospital in Zanzibar using patient trajectories and mathematical modeling.

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

Severe maternal morbidity in Zanzibar's referral hospital: Measuring the impact of in-hospital care.

OBJECTIVE: to analyse the impact of in-hospital care on severe maternal morbidity using WHO's near-miss approach in the low-resource, high mortality setting of Zanzibar's referral hospital. SETTING: Mnazi Mmoja Hospital, a tertiary care facility, in Zanzibar, Tanzania. METHODS: We identified all cases of morbidity and mortality in women admitted within 42 days after the end of pregnancy at Mnazi Mmoja Hospital in the period from April to October 2016. The severity of complications was classified using WHO's near-miss approach definitions: potentially life-threatening condition (PLTC), maternal near-miss (MNM) or maternal death (MD). Quality of in-hospital care was assessed using the mortality index (MI) defined as ratio between mortality and severe maternal outcome (SMO) where SMO = MD + MNM, cause-specific case facility rates and comparison with predicted mortality based on the Maternal Severity Index model. MAIN OUTCOMES: 5551 women were included. 569 (10.3%) had a potentially life-threatening condition and 65 (1.2%) a severe maternal outcome (SMO): 37 maternal near-miss cases and 28 maternal deaths. The mortality index was high at 0.43 and similar for women who developed a SMO within 12 hours of admission and women who developed a SMO after 12 hours. A standardized mortality ratio of 6.03 was found; six times higher than that expected in moderate maternal mortality settings given the same severity of cases. Obstetric haemorrhage was found to be the main cause of SMO. Ruptured uterus and admission to ICU had the highest case-fatality rates. Maternal death cases seemed to have received essential interventions less often. CONCLUSIONS: WHO's near-miss approach can be used in this setting. The high mortality index observed shows that in-hospital care is not preventing progression of disease adequately once a severe complication occurs. Almost one in two women experiencing life-threatening complications will die. This is six times higher than in moderate mortality settings.

Identification of first-stage labor arrest by electromyography in term nulliparous women after induction of labor.

INTRODUCTION: Worldwide induction and cesarean delivery rates have increased rapidly, with consequences for subsequent pregnancies. The majority of intrapartum cesarean deliveries are performed for failure to progress, typically in nulliparous women at term. Current uterine registration techniques fail to identify inefficient contractions leading to first-stage labor arrest. An alternative technique, uterine electromyography has been shown to identify inefficient contractions leading to first-stage arrest of labor in nulliparous women with spontaneous onset of labor at term. The objective of this study was to determine whether this finding can be reproduced in induction of labor. MATERIAL AND METHODS: Uterine activity was measured in 141 nulliparous women with singleton term pregnancies and a fetus in cephalic position during induced labor. Electrical activity of the myometrium during contractions was characterized by its power density spectrum. RESULTS: No significant differences were found in contraction characteristics between women with induced labor delivering vaginally with or without oxytocin and women with arrested labor with subsequent cesarean delivery. CONCLUSION: Uterine electromyography shows no correlation with progression of labor in induced labor, which is in contrast to spontaneous labor.

Uterine electromyography for identification of first-stage labor arrest in term nulliparous women with spontaneous onset of labor.

OBJECTIVE: We sought to study whether uterine electromyography (EMG) can identify inefficient contractions leading to first-stage labor arrest followed by cesarean delivery in term nulliparous women with spontaneous onset of labor. STUDY DESIGN: EMG was recorded during spontaneous labor in 119 nulliparous women with singleton term pregnancies in cephalic position. Electrical activity of the myometrium during contractions was characterized by its power density spectrum (PDS). RESULTS: Mean PDS peak frequency in women undergoing cesarean delivery for first-stage labor arrest was significantly higher (0.55 Hz), than in women delivering vaginally without (0.49 Hz) or with (0.51 Hz) augmentation of labor (P = .001 and P = .01, respectively). Augmentation of labor increased the mean PDS frequency when comparing contractions before and after start of augmentation. This increase was only significant in women eventually delivering vaginally. CONCLUSION: Contraction characteristics measured by uterine EMG correlate with progression of labor and are influenced by labor augmentation.

A validation of electrohysterography for uterine activity monitoring during labour.

OBJECTIVES: Validation of electrohysterography (EHG) as a method for uterine activity monitoring during labour by comparing with intra-uterine pressure catheter (IUPC) recordings. DESIGN: Prospective observational study. SETTING: Labour ward in a tertiary centre in the Netherlands. POPULATION: Thirty-two women in labour. METHODS: Simultaneous recording of uterine activity with EHG and IUPC for at least 30 min. MAIN OUTCOME MEASURES: Number of uterine contractions detected by both EHG and IUPC (sensitivity). Number of contractions detected by EHG only [positive predictive value (PPV)]. Correlation between contraction amplitude and duration measured by EHG and IUPC. RESULTS: EHG detects uterine contractions accurately: sensitivity = 94.5% (95%CI: 87.5-100), PPV = 88.3% (95%CI: 76.2-100). The correlation of contractions' duration and amplitude between both methods is r = 0.31 (95%CI: 0.23-0.39) and r = 0.45 (95%CI: 0.38-0.52), respectively. CONCLUSIONS: EHG detects uterine contractions accurately during labour but the contraction's characteristics it measures are not directly comparable with that of IUPC.