How many maternal deaths are there in Portugal?

Introduction: Maternal mortality is a public health issue, internationally considered an indicator of women’s status in society, indirectly translating access to health facilities. However, it is difficult to measure and is usually underestimated by official records. Methods: Maternal deaths missed by the official statistics in Portugal between 2001 and 2006 were estimated by multiple-recapture methods using three different data sources. An upper limit to the number of deaths was derived from the application of the mortality function of women in reproductive age to the estimated annual number of pregnancies. Results: Maternal mortality decreased from 40 to less than 10 deaths per 100?000 live births between 1978 and 1986. Between 2001 and 2006, it varied from 2.5 to 19 and was underestimated by 9%–26%. Nevertheless, within the same age range, the risk of a pregnant women to die was four times less than a women in the general population. Conclusion: Like in other developed countries, official statistics in Portugal have systematically underestimated maternal deaths. These deaths are a rare event, but the consistent increase in the average age at pregnancy may exacerbate the main causes of death, raising concerns for the future and prompting the need for emergency facilities nearby maternities.     

Seizing the big missed opportunity: linking HIV and maternity care services in sub-Saharan Africa

This paper draws on two reviews commissioned by the UK Department for International Development in 2006-2007 that explore progress in linking HIV prevention and maternity services in sub-Saharan Africa. Although pilot and demonstration projects have been successful, progress in scaling up PMTCT has been slow, reaching just 11% of pregnant HIV positive women in much of Africa, less than half the percentage of coverage achieved by antiretroviral treatment programmes for adults in need. Despite ongoing efforts to promote comprehensive approaches, significant policy, financing and institutional barriers, and weak co-ordination and leadership, continue to hamper progress. Maternal health services face human and financial resource shortages which affect their capacity to integrate HIV prevention. Both HIV and maternal health programmes often receive targeted financial and technical assistance that does not take the other into account. However, proposals in 2007 from a number of countries to the Global Fund to Fight AIDS, TB and Malaria incorporate sexual and reproductive health programming that will have an impact on HIV, including certain maternity services. Moreover, Botswana, Kenya and Rwanda have shown that progress can be made where national commitment and increased resources are enabling maternal and newborn care to address HIV.     

Low use of rural maternity services in Uganda: impact of women's status,traditional beliefs and limited resources

In Uganda, lack of resources and skilled staff to improve quality and delivery of maternity services, despite good policies and concerted efforts, have not yielded an increase in utilisation of these services by women or a reduction in the high ratio of maternal deaths. This paper reports a study conducted from November 2000 to October 2001 in Hoima, a rural district in western Uganda, whose aim was to enhance understanding of why, when faced with complications of pregnancy or delivery, women continue to choose high risk options leading to severe morbidity and even their own deaths. The findings demonstrate that adherence to traditional birthing practices and beliefs that pregnancy is a test of endurance and maternal death a sad but normal event, are important factors. The use of primary health units and the referral hospital, including when complications occur, was considered only as a last resort. Lack of skilled staff at primary health care level, complaints of abuse, neglect and poor treatment in hospital and poorly understood reasons for procedures, plus health workers' views that women were ignorant, also explain the unwillingness of women to deliver in health facilities and seek care for complications. Appropriate interventions are needed to address the barriers between rural mothers and the formal health care system, including community education on all aspects of essential obstetric care and sensitisation of service providers to the situation of rural mothers.     

Program note: Using UN process indicators to assess needs in emergency obstetric services: Bolivia, El Salvador and Honduras.

The UN process indicators are used to assess the availability, utilization and quality of emergency obstetric care (EmOC). Needs assessments for EmOC in Bolivia, El Salvador and Honduras show reasonable availability of comprehensive EmOC facilities for their population sizes, but a scarcity of basic facilities. Utilization rates among women with obstetric complications are high in El Salvador and Honduras. Case fatality rates tend to be below 1% in all three countries, but the more rural areas in each have poorer indicators.     

National Partnership for Maternal Safety: Consensus Bundle on Support After a Severe Maternal Event

Supporting women, families, and clinicians with information, emotional support, and health care resources should be part of an institutional response after a severe maternal event. A multidisciplinary approach is needed for an effective response during and after the event. As a member of the maternity care team, the nurse’s role includes coordination, documentation, and ensuring patient safety in emergency situations. The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women’s Health Care, has developed interprofessional work groups to develop safety bundles on diverse topics. This article provides the rationale and supporting evidence for the support after a severe maternal event bundle, which includes structure- and evidence-based resources for women, families, and maternity care providers. The bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning, and it may be adapted by nurses and multidisciplinary leaders in birthing facilities for implementation as a standardized approach to providing support for everyone involved in a severe maternal event.     

The status of maternal and newborn care services in Sierra Leone 8 years after ceasefire

Objective

To conduct a needs assessment for emergency obstetric care (EmOC) to address the unacceptably high maternal and newborn mortality indices in Sierra Leone 8 years after the end of the civil war.

Methods

From June to August 2008, a cross-sectional survey was conducted of health facilities in Sierra Leone offering delivery services. Assessment tools were local adaptations of tools developed by the Averting Maternal Death and Disability program at Columbia University, New York, USA.

Results

There were enough comprehensive EmOC (CEmOC) facilities in the country but they were poorly distributed. There were no basic EmOC (BEmOC) facilities. Few facilities (37% of hospitals and 2% of health centers) were able to perform assisted vaginal delivery (AVD), and 3 potentially BEmOC facilities did not meet the standard only because they did not perform AVD. Severe shortages in staff, equipment, and supplies, and unsatisfactory supply of utilities severely hampered the delivery of quality EmOC services. Demand for maternity and newborn services was low, which may have been related to the poor quality and the high/unpredictable out-of-pocket cost of such services.

Conclusion

Significant increases in the uptake of institutional delivery services, the linkage of remote health workers to the health system, and the recruitment of midwives, in addition to rapid expansion in the training of health workers (including training in midwifery and obstetric surgery skills), are urgently needed to improve the survival of mothers and newborns.     

Support to the Safe Motherhood Programme in Nepal: an integrated approach

Evidence gathered from 1997 to 2006 indicates progress in reducing maternal mortality in Nepal, but public health services are still constrained by resource and staff shortages, especially in rural areas. The five-year Support to the Safe Motherhood Programme builds on the experience of the Nepal Safer Motherhood Project (1997-2004). It is working with the Government of Nepal to build capacity to institute a minimum package of essential maternity services, linking evidence-based policy development with health system strengthening. It has supported long-term planning, working towards skilled attendance at every birth, safe blood supplies, staff training, building management capacity, improving monitoring systems and use of process indicators, promoting dialogue between women and providers on quality of care, and increasing equity and access at district level. An incentives scheme finances transport costs to a health facility for all pregnant women and incentives to health workers attending deliveries, with free services and subsidies to facilities in the poorest 25 districts. Despite bureaucracy, frequent transfer of key government staff and political instability, there has been progress in policy development, and public health sector expenditure has increased. For the future, a human resources strategy with career paths that encourage skilled staff to stay in the government service is key.     

Why do mothers die in Dakahlia, Egypt?

AIM: To investigate the causes of maternal mortality in the Dakahlia Governorate in Egypt. METHODS: A confidential enquiry for each case of maternal mortality during the years 2004-2005 was carried out. RESULTS: One hundred and seventy-nine maternal deaths were reported, giving a maternal mortality rate (MMR) of 71.3/100,000 live births. 140 (78.2%) women died due to direct obstetric causes, 24 (13.4%) due to indirect causes and 15 (8.4%) due to accidental or unexplained causes. 44 (24.6%) women died during or following delivery by cesarean section and 91 (50.8%) during labor or within 24 h following delivery. Complications during cesarean delivery, postpartum hemorrhage and hypertensive disorders were the leading causes of maternal mortality. Death due to substandard care was encountered in 85% of cases. Obstetricians were responsible for 51% of causes of avoidable maternal death. CONCLUSION: Maternal mortality in Dakahlia, although declining, is still relatively high. To further reduce maternal mortality, deliveries should be conducted at well-equipped hospitals.     

Priorities in emergency obstetric care in Bolivia––maternal mortality and near-miss morbidity in metropolitan La Paz

Objective  To document the frequency and causes of maternal mortality and severe (near-miss) morbidity in metropolitan La Paz, Bolivia.
Design  Facility-based cross-sectional study.
Setting  Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government-subsidised programme.
Population  All maternal deaths and women with near-miss morbidity.
Methods  Inclusion of near-miss using clinical and management-based criteria.
Main outcome measures  Maternal mortality ratio (MMR), severe morbidity ratio (SMR), mortality indices and proportion of near-miss cases at hospital admission.
Results  MMR was 187/100 000 live births and SMR was 50/1000 live births, with a relatively low mortality index of 3.6%. Severe haemorrhage and severe hypertensive disorders were the main causes of near-miss, with 26% of severe haemorrhages occurring in early pregnancy. Sepsis was the most common cause of death. The majority of near-miss cases (74%) were in critical condition at hospital admission and differed from those fulfilling the criteria after admission as to diagnostic categories and socio-demographic variables.
Conclusions  Pre-hospital barriers remain to be of great importance in a setting of this type, where there is wide availability of free maternal health care. Such barriers, together with haemorrhage in early pregnancy, pre-eclampsia detection and referral patterns, should be priority areas for future research and interventions to improve maternal health. Near-miss upon arrival and near-miss after arrival at hospital should be analysed separately as that provides additional information about factors that contribute to maternal ill-health.     

Improving emergency obstetric care in a context of very high maternal mortality: the Nepal Safer Motherhood Project 1997-2004

The Nepal Safer Motherhood Project (1997-2004) was one of the first large-scale projects to focus on access to emergency obstetric care, covering 15% of Nepal. Six factors for success in reducing maternal mortality are applied to assess the project. There was an average annual increase of 1.3% per year in met need for emergency obstetric care, reaching 14% in public sector facilities in project districts in 2004. Infrastructure and equipment to achieve comprehensive-level care were improved, but sustained functioning, availability of a skilled doctor, blood and anaesthesia, were greater challenges. In three districts, 70% of emergency procedures were managed by nurses, with additional training. However, major shortages of skilled professionals remain. Enhancement of the weak referral system was beyond the project's scope. Instead, it worked to increase information in the community about danger signs in pregnancy and delivery and taking prompt action. A key initiative was establishing community emergency funds for obstetric complications. Efforts were also made to develop a positive shift in attitudes towards patient-centred care. Supply-side interventions are insufficient for reducing the high level of maternal deaths. In Nepal, this situation is complicated by social norms that leave women undervalued and disempowered, especially those from lower castes and certain ethnic groups, a pattern reflected in use of maternity services. Programming also needs to address the social environment.     

Safety and usefulness of emergency maternal transport using helicopter

AIM: Japan has a shortage of tertiary medical care facilities for maternal and fetal medicine. Establishment of efficient medical transport systems is needed for pregnant women and fetuses with severe complications. Maternal transport by helicopters is expected to shorten transportation time to advanced facilities, although its feasibility has not yet been evaluated. The aim of the present study was to investigate the status of maternal helicopter transport, and conditions of the pregnant patients and children transferred by helicopter to Kameda Medical Center (KMC). METHODS: Between August 2005 and July 2006, 26 pregnant women were transported by helicopters to KMC. RESULTS: The median net flight time was 24 min (range 15-29 min), and the median of estimation of ground transportation time was 125 min (range 90-180 min). The causes for transfers were preterm labor in eight, preterm premature rupture of the membrane in five, cervical incompetence in five, pre-eclampsia in three and other medical reasons in five. Five of the 26 patients were discharged with restored stability of pregnancy. The remaining 21 patients underwent delivery at KMC. The median gestational age was 26 weeks (range 22-33 weeks) at the time of transfer and 31 weeks (range 22-37 weeks) at delivery. Four of 26 neonates who were born at KMC died after birth due to severe premature or congenital anomaly. Seventeen of the remaining 22 neonates, including 10 twins, received treatment in the neonatal intensive care unit. All of the 22 neonates and all the mothers were discharged in good condition. No patients developed any complications requiring treatment during flights. CONCLUSION: Helicopter transfer is feasible for pregnant patients with severe complications.     

The Turkey National Maternal Mortality Study

Objective Complications during pregnancy, delivery and puerperium are the most widespread causes of death and disability among women of reproductive age in developing countries. In most of these, reliable estimates of maternal mortality are lacking. This paper aims to report Turkey's basic maternal mortality indicators derived from the National Maternal Mortality Study (NMMS).

Methods The data originate from NMMS which was an implementation of a Reproductive Age Mortality Study (RAMOS) data-collection strategy. Maternal mortality rates and ratios were estimated, and information was gathered for improving the existing recording and reporting systems. Burial data by age and sex were collected prospectively over a 12 month period. Interviews with household members, health care providers, and reviews of facility records were then used to classify the deaths as pregnancy-related or maternal or otherwise.

Results A national pregnancy-related mortality ratio of 38 (± 2.8) and a maternal mortality ratio of 29 (± 2.5) per 100,000 live births were found. The NMMS shows that 59% of all pregnant women died from direct maternal causes, 16% from indirect causes and 23% from co-incidental causes.

Conclusion Maternal mortality is highest in regions with a poorer network of good roads, harsher winter conditions and longer distances to the next secondary level health facility which provides comprehensive obstetric emergency care services.     

Maternal mortality in Pernambuco, Brazil: what has changed in ten years?

This study examines changes in levels and patterns of maternal mortality in Pernambuco, Brazil, in 1994 and 2003. The research was carried out in five sub-regions of Pernambuco using the Reproductive Age Mortality Survey (RAMOS) method and based on death certificates of women of reproductive age registered in the local System of Information on Mortality. In-depth interviews with family members were also conducted for the abortion-related deaths. Of the 1,258 female deaths investigated, 54 maternal deaths were identified, corresponding to a maternal mortality ratio of 77 per 100,000 live births. The estimated level of under-reporting (46%) corresponds to an upward adjustment factor of 1.9. The illegal status of abortion in Brazil remains an important contributory factor for the abortion-related deaths. Approximately 94% of the maternal deaths were judged to be avoidable with improvements in health care. Maternal mortality declined by 30% over the ten-year period but the level of misclassification of maternal deaths remains. Improvements in maternity care for women and reporting of maternal deaths are still urgently needed.     

Emergency obstetric care in Pakistan: potential for reduced maternal mortality through improved basic EmOC facilities, services, and access.

OBJECTIVE: To ascertain and compare compliance with UN emergency obstetric care (EmOC) recommendations by public health care centers in Pakistan's Punjab and Northwest Frontier Province (NWFP) provinces. METHOD: Cross-sectional data were collected from July through September 2003 using UN process indicators. From each province, 30% of districts (n=19); were randomly selected; all public health facilities providing EmOC services (n=170) were included. RESULTS: The study found that out of 170 facilities only 22 were providing basic and 37 comprehensive EmOC services in the areas studied. Only 5.7% of births occurred in EmOC health facilities. Met need was 9% and 0.5% of women gave birth by cesarean section. The case fatality rate was a low 0.7%, probably due to poor record keeping. Access and several indicators were better in NWFP than in Punjab. CONCLUSION: Almost all indicators were below UN recommendations. Health policy makers and planners must take immediate, appropriate measures at district and hospital levels to reduce maternal mortality.     

Availability and quality of emergency obstetric and neonatal care services in Afghanistan

ObjectiveTo assess the availability and utilization of emergency obstetric and neonatal care (EmONC) facilities in Afghanistan, as defined by UN indicators.MethodsIn a cross-sectional study of 78 first-line referral facilities located in secure areas of Afghanistan, EmONC service delivery was evaluated by using Averting Maternal Deaths and Disabilities (AMDD) Program assessment tools.ResultsForty-two percent of peripheral facilities did not perform all 9 signal functions required of comprehensive EmONC facilities. The study facilities delivered 17% of all neonates expected in their target populations and treated 20% of women expected to experience direct complications. The population-based rate of cesarean delivery was 1%. Most maternal deaths (96%) were due to direct causes. The direct and indirect obstetric case fatality rates were 0.8% and 0.2%, respectively.ConclusionNotable progress has been made in Afghanistan over the past 8 years in improving the quality, coverage, and utilization of EmONC services, but gaps remain. Re-examination of the criteria for selecting and positioning EmONC facilities is recommended, as is the provision of high-quality, essential maternal and neonatal health services at all levels of the healthcare system, linked by appropriate communication and functional referral systems.     

The Experience of Pregnancy and Birth with Midwives: Results from the Canadian Maternity Experiences Survey

Abstract: Background: In Canada maternity care is publicly funded, and although women may choose their care providers, choices may be limited. The purpose of this study was to compare perceptions of maternity outcomes and experiences of those who received care from midwives with those who received care from other providers. Methods: Based on the 2006 Canadian census, a random sample of women (n = 6,421) who had recently given birth in Canada completed a computer‐assisted telephone interview for the Maternity Experiences Survey. The sample was stratified according to province or territory where birth occurred, age, rural or urban residence, and presence of other children in the home. Those who were 15 years of age and older, gave birth to a singleton baby, and were living with their infant were eligible for inclusion. Results: Women whose primary prenatal providers were midwives had fewer ultrasounds and were more likely to attend prenatal classes and have at least five or more prenatal visits. They were also more likely to rate satisfaction with their maternity experience as “very positive” and be satisfied with information provided on a variety of pregnancy and birth topics if their primary prenatal provider was a midwife. They were almost half as likely to experience induction and 7.33 times more likely to experience a medication‐free delivery. They were more likely to initiate and maintain breastfeeding at 3 and 6 months. Conclusions: Evidence shows that midwifery outcomes and levels of satisfaction meet or exceed Canadian maternity care standards. Facilitation of the continuing integration of midwives as autonomous practitioners throughout Canada is recommended. (BIRTH 38:3 September 2011)     

Managing sepsis in pregnancy

Maternal sepsis is a major contributor to global maternal mortality. The physiological changes associated with pregnancy can obscure some of the recognised signs and symptoms of sepsis. Modified early obstetric warning score charts and sepsis screening tools aid the early identification of the septic patient. Management of maternal sepsis should involve the whole multidisciplinary team and is centred on urgent resuscitation, promt initiation of antimicrobial therapy and source control. There are logistical challenges in managing maternal sepsis in the peripartum period requiring close collaboration betwen critical care and maternity services.     

Improvement of coverage and utilization of EmOC services in southwestern Bangladesh.

OBJECTIVE: The Government of Bangladesh has implemented safe motherhood programs throughout the country supported by the United Nations Children's Fund (UNICEF) and United Nations Population Fund (UNFPA) aimed at reducing maternal morbidity and mortality. The objective of this study is to assess the effect of the interventions on the UN emergency obstetric care (EmOC) process indicators in Khulna division, Bangladesh. METHODS: Of the 71 government health facilities in Khulna division, 32 were providing comprehensive and 20 were providing basic EmOC services. Another 4 facilities were providing comprehensive or basic EmOC services during the first three-quarters but became non-functional during the last quarter. EmOC data, from January to December 2002, were collected from all these 56 facilities to determine the levels of EmOC process indicators relative to the UN guidelines and compared with baseline data from 1998 to 1999. RESULTS: There were 1.04 and 0.64 comprehensive and basic EmOC facilities respectively per 500,000 population. When compared with the baseline data, the coverage of comprehensive EmOC services was substantially increased from 0.23 to 1.04 per 500,000 population, which achieves the minimum UN standards but the coverage of basic EmOC services remained the same. The data also showed that, compared with the baseline survey, the proportion of births at the EmOC facilities increased 119% from 5.3% to 11.7% (p<0.001), met need increased 141% from 11.1% to 26.6% (p<0.001), and cesarean section as a proportion of all expected births, increased 151% from 0.5% to 1.3% (p<0.001), while the overall case fatality rate (CFR) decreased by 51% (p<0.001). CONCLUSION: With the exception of coverage of basic EmOC after the interventions, there was significant improvement in all the EmOC process indicators in Khulna division. However, most of the process indicators are still far from the minimum recommended UN standards. RECOMMENDATIONS: Efforts should continue to keep the EmOC facilities functional 24/7 while increasing the number of basic EmOC facilities, and improving utilization of services to reach the minimum UN standards. Community mobilization should be directed to understand the danger signs and utilization of services at functional facilities when necessary. Further research to identify the factors influencing utilization of EmOC services and continuous monitoring and periodical assessment of the process indicators are recommended to evaluate the overall situation from time to time.     

Barriers to access adequate maternal care in Romania,Bulgaria, and Moldova: A cross-country comparison

Background

Eastern European health system indicators (e.g., number of health workers and care coverage) suggest well-resourced maternity care systems, but maternal health outcomes compare poorly with those in Western Europe. Often, poor maternal health outcomes are linked to inequities in accessing adequate maternal care. This study investigates access-related barriers (availability, appropriateness, affordability, approachability, and acceptability) to maternity care in Romania, Bulgaria, and Moldova.

Methods

This cross-country study (n = 7345) is based on an online survey where women who received maternity care and gave birth in 2015–2018 in Bulgaria (n = 4951), Romania (n = 2018), and Moldova (n = 376) provided information on their experiences with the care received. We used regression analysis to identify factors associated with accessing maternity care across the three countries.

Results

Results show high rates of cesarean births (CB) and a low number of antenatal and postnatal care visits. Informal payments and use of personal connections are common practices. Formal and informal out-of-pocket payments create a financial burden for women with health complications. Women who had health complications, those who gave birth by cesarean, and women who gave birth in a public facility and had fewer antenatal check-ups, were more likely to describe facing access-related barriers.

Conclusions

This study identifies several barriers to high-quality maternity care in Romania, Bulgaria and Moldova. More attention should be paid to the appropriateness of care provided to women with complicated pregnancies, to those who have CBs, to women who give birth in public facilities, and to those who receive fewer antenatal care visits.     

Use of maternal care in a rural area of Zimbabwe: a population-based study

PURPOSE: Our aim was to determine the coverage of antenatal and delivery care and the determinants of non-compliance in a rural area of Zimbabwe in order to improve the quality and efficiency of maternal health care services. METHODS: A community-based, cross-sectional study was carried out in the catchment area of Gutu Mission Hospital, in rural Zimbabwe, from January to June 1996. Two hundred and thirty-five women, aged 16 to 54 years, who had delivered a child in the past three years were interviewed on general characteristics (age, marital status, religion, education, work), obstetric history, use of family planning, pregnancy complications, number of antenatal visits, and use of maternity waiting shelters. Associations of these factors to non-use of antenatal care facilities and hospital delivery were studied. In the Gutu district, guidelines exist to identify women at high risk of complications during pregnancy and to indicate where women should give birth (hospital, rural clinic or at home). We evaluated which factors were important for non-compliance to these guidelines. The analyses were performed using a logistic regression model. RESULTS: Ninety-seven percent of the pregnant women attended the antenatal care facilities at least once. Seventy-three percent came at least five times or more. Belonging to certain religious groups proved to be the strongest explanatory factor for not attending antenatal care facilities. Use of maternity waiting shelters and complications during the pregnancy were important factors for hospital delivery, whereas unemployment and being without a husband were associated with deliveries outside the hospital. Identification as high risk of a complicated pregnancy by application of the existing guidelines was not associated with place of delivery. Delivery at a location that did not conform to the existing guidelines was associated with non-use of maternity waiting shelters, unemployment or being without a husband and use of traditional care. CONCLUSIONS: Our study showed a high attendance rate at antenatal care facilities in the Gutu District. By analyzing determinants of non-use of antenatal care facilities, of hospital delivery and of inappropriate location of delivery according to local guidelines, we identified certain risk factors which are suitable for modification and may help to improve antenatal and perinatal care in the Gutu District in Zimbabwe.