The effect of maternal HIV status on perinatal outcome at Mowbray Maternity Hospital and referring midwife obstetric units Cape Town

Objectives. To study the effect of maternal HIV status on perinatal outcome at Mowbray Maternity Hospital (a secondary-level hospital in Cape Town) and its satellite community midwife obstetric units. Design. A retrospective descriptive and comparative study.Setting. Public sector maternity facilities serving historically disadvantaged populations. Subjects. All deliveries at Mowbray Maternity Hospital and its referral midwife obstetric units from January to December 2008. Outcome measures. Stillbirth, early neonatal death, perinatal mortality and neonatal encephalopathy rates in HIV-positive and HIVnegative subjects. Results. There was a total of 18 870 deliveries at the units studied, 3 259 (17.2%) of them to HIV-positive mothers. The stillbirth rate in the HIV-positive population was 17.1/1 000 births, compared with 8.3/1 000 in the HIV-negative population (odds ratio (OR), 2.07, 95% confidence interval (CI) 1.5 - 2.8). The early neonatal death rate in the HIV-positive population was 4.6/1 000 live births, compared with 3.1/1 000 in the HIV-negative population (OR 1.46, 95% CI 0.8 - 2.6). The perinatal mortality rate in the HIV-positive population was 21.7/1 000 births, compared with 11.7 in the HIV-negative population (OR 1.91, 95% CI 1.4 - 2.5). A comparison of the pattern of primary obstetric causes of perinatal mortality showed that infection, intra-uterine growth restriction (IUGR) and antepartum haemorrhage (APH) were significantly more common as causes for perinatal death in the HIV-positive population. The risk of neonatal encephalopathy in the HIV-exposed population was 4.9/1 000 live births compared with 2.07 in the HIV-negative group (OR 2.36, 95% CI 1.28 - 4.35). The 1 643 women (8.7% of total deliveries) who were not tested for HIV were at particularly high risk of adverse perinatal outcome. This group included women who had either declined testing or not attended for antenatal care. Conclusion. The perinatal mortality rate in the group of HIV-exposed mothers was significantly higher than that in the HIV-negative group due to a higher stillbirth rate. Infection, IUGR and APH were significantly more common obstetric causes for mortality in the HIV-infected population. The risk of neonatal encephalopathy was also significantly higher in the HIV-positive population

Abuse in South African maternity settings is a disgrace: Potential solutions to the problem

Abuse of mothers in maternity settings is widespread globally. In South Africa, this human rights violation has been documented by many sources. Particular factors relating to health workers’ professional and personal contexts contribute to the problem and need to be addressed if it is to be solved. Several local and international initiatives are discussed as possible solutions

Maternal death and caesarean section in South Africa: Results from the 2011 - 2013 Saving Mothers Report of the National Committee for Confidential Enquiries into Maternal Deaths

Background. In the latest (2011 - 2013) Saving Mothers report, the National Committee for Confidential Enquiries into Maternal Deaths in South Africa (SA) (NCCEMD) highlights the large number of maternal deaths associated with caesarean section (CS). The risk of a woman dying as a result of CS during the past triennium was almost three times that for vaginal delivery. Of all the mothers who died during or after a CS, 3.4% died during the procedure and 14.5% from haemorrhage afterwards. Including all cases of death from obstetric haemorrhage where a CS was done, there were 5.5 deaths from haemorrhage for every 10 000 CSs performed.Objective. To scrutinise the contribution or effect of the surgical procedure on the ultimate cause of death by a cross-cutting analysis of the 2011 - 2013 national data.Methods. Data from the 2011 - 2013 triennial review were entered into an Excel database and analysed on a national and provincial basis.Results. There were 1 243 maternal deaths where a CS was the mode of delivery and 1 471 deaths after vaginal delivery. More mothers died as a result of CS in the provinces where there is a low overall CS rate. The following CS categories were identified as specific problems: bleeding during or after CS, pre-eclampsia and eclampsia, anaesthesia-related deaths, pregnancy-related sepsis and acute collapse and embolism.Conclusion. This is an area of concern, and a concentrated effort should be done to make CS in SA safer. Several recommendations are made to this effect

The epidemiology of incomplete abortion in South Africa

Objective. To describe the epidemiology of incomplete abortion (spontaneous miscarriage and illegally induced) in South Africa.Design. Multicentre, prospective, descriptive study.Setting. Fifty-six public hospitals in nine provinces (a stratified, random sample of all hospitals treating gynaecological emergencies).Patients. All women of gestation under 22 weeks who presented with incomplete abortion during the 2-week study period.Main outcome measures. Incidence of, morbidity associated with and mortality from incomplete abortion.Main results. An estimated 44 686 (95% Cl 35 633 - 53 709) women per year were admitted to South Africa's public hospitals with incomplete abortion. An estimated 425 (95% Cl 78 - 735) women die in public hospitais from complications of abortion. Fifteen per cent (95% Cl 13 18) of patients have severe morbidity while a further 19% (95% Cl 16 - 22) have moderate morbidity, as assessed by categories designed for the study which largely reflect infection. There were marked inter-provincial differences  and inter-age group differences in trimester of presentation and proportion of patients with appreciable morbidity.Conclusions. Incomplete abortions and, in particular, unsafe abortions are an important cause of mortality and morbidity in South Africa. The methods used in this study underestimate the true incidence for reasons that are discussed. A high priority should be given to the prevention of unsafe abortion

Maternal mortality in the covid-19 pandemic: findings from a rapid systematic review

BACKGROUND: The COVID-19 pandemic is having significant direct and associated effects on many health outcomes, including maternal mortality. As a useful marker of healthcare system functionality, trends in maternal mortality provide a lens to gauge impact and inform mitigation strategies. OBJECTIVE: To report the findings of a rapid systematic review of studies on levels of maternal mortality before and during the COVID-19 pandemic. METHODS: We systematically searched for studies on the 1st March 2021 in MEDLINE and Embase, with additional studies identified through MedRxiv and searches of key websites. We included studies that reported levels of mortality in pregnant and postpartum women in time-periods pre- and during the COVID-19 pandemic. The maternal mortality ratio was calculated for each study as well as the excess mortality. RESULTS: The search yielded 3411 references, of which five studies were included in the review alongside two studies identified from grey literature searches. Five studies used data from national health information systems or death registries (Mexico, Peru, Uganda, South Africa, and Kenya), and two studies from India were record reviews from health facilities. There were increased levels of maternal mortality documented in all studies; however, there was only statistical evidence for a difference in maternal mortality in the COVID-19 era for four of these. Excess maternal mortality ranged from 8.5% in Kenya to 61.5% in Uganda. CONCLUSIONS: Measuring maternal mortality in pandemics presents many challenges, but also essential opportunities to understand and ameliorate adverse impact both for women and their newborns. Our systematic review shows a dearth of studies giving reliable information on levels of maternal mortality, and we call for increased and more systematic reporting of this largely preventable outcome. The findings help to highlight four measurement-related issues which are priorities for continuing research and development

Maternal mortality in the covid-19 pandemic: findings from a rapid systematic review

BACKGROUND: The COVID-19 pandemic is having significant direct and associated effects on many health outcomes, including maternal mortality. As a useful marker of healthcare system functionality, trends in maternal mortality provide a lens to gauge impact and inform mitigation strategies. OBJECTIVE: To report the findings of a rapid systematic review of studies on levels of maternal mortality before and during the COVID-19 pandemic. METHODS: We systematically searched for studies on the 1st March 2021 in MEDLINE and Embase, with additional studies identified through MedRxiv and searches of key websites. We included studies that reported levels of mortality in pregnant and postpartum women in time-periods pre- and during the COVID-19 pandemic. The maternal mortality ratio was calculated for each study as well as the excess mortality. RESULTS: The search yielded 3411 references, of which five studies were included in the review alongside two studies identified from grey literature searches. Five studies used data from national health information systems or death registries (Mexico, Peru, Uganda, South Africa, and Kenya), and two studies from India were record reviews from health facilities. There were increased levels of maternal mortality documented in all studies; however, there was only statistical evidence for a difference in maternal mortality in the COVID-19 era for four of these. Excess maternal mortality ranged from 8.5% in Kenya to 61.5% in Uganda. CONCLUSIONS: Measuring maternal mortality in pandemics presents many challenges, but also essential opportunities to understand and ameliorate adverse impact both for women and their newborns. Our systematic review shows a dearth of studies giving reliable information on levels of maternal mortality, and we call for increased and more systematic reporting of this largely preventable outcome. The findings help to highlight four measurement-related issues which are priorities for continuing research and development

The impact of COVID-19 on use of maternal and reproductive health services and maternal and perinatal mortality

South Africa experienced two waves of COVID-19 infection in the financial year 2020/21. This study examines the impact of these waves on maternal and perinatal mortality and their effect on the use of and access to maternal and reproductive health services. Data from the District Health Information System on maternal and perinatal deaths, births, antenatal visits, and use of contraceptive termination of pregnancy services were used, and the 2020/21 and 2019/20 financial years were compared in order to formulate national and provincial perspectives. Data on visits for initiating antenatal care, births, contraceptive prescriptions and termination-of-pregnancy services were used to assess utilisation of maternal and reproductive health services respectively; and the number and rates of maternal and perinatal deaths were examined to assess impact. A second descriptive analysis of pregnant women who had delivered after having contracted COVID-19 was performed using a separate database set up by the National Department of Health/South African Medical Research Council/University of Pretoria (NDoH/ SAMRC/UP), specifically to monitor the effects of COVID-19). The data suggest that there was a marked increase (of 40%) in maternal deaths (p<0.00001), 10% in stillbirths (p<0.00001), and 3% in (p=0.31) neonatal deaths when compared with the same period in 2019/20. There was a mean 28% increase in the institutional maternal mortality ratio in all provinces during the second wave compared with the first wave (p<0.0001), except in the Western Cape which had a decrease of 1%. Data from the National Institute for Communicable Diseases showed that the case fatality rate for pregnant women with COVID-19 was high (4.5%), as was the perinatal mortality rate (70.6 per 1 000 births), while the institutional maternal mortality ratio for South Africa was 16.94/100 000 live births. An increase of 3.6% in in-facility births in 2020/21 compared with 2019/20 was observed, with increased movement of pregnant women to the more rural provinces and districts for delivery. Antenatal care services were maintained overall, but use of reproductive health services declined (contraceptive prescriptions by 5%, and termination of pregnancy by 17% overall). The effect of the COVID-19 epidemic on pregnant women and its collateral damage is severe. Strengthening the health system to maintain essential services during a pandemic and vaccination of healthcare workers and pregnant women are key to reducing maternal and perinatal mortality.http://www.journals.co.za/content/journal/healthrObstetrics and Gynaecolog

Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions

BACKGROUND: Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for skilled birth attendance and basic and comprehensive emergency obstetric care. RESULTS: Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships. CONCLUSIONS: Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery

Formative research to design an implementation strategy for a postpartum hemorrhage initial response treatment bundle (E-MOTIVE): study protocol

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. When PPH occurs, early identification of bleeding and prompt management using evidence-based guidelines, can avert most PPH-related severe morbidities and deaths. However, adherence to the World Health Organization recommended practices remains a critical challenge. A potential solution to inefficient and inconsistent implementation of evidence-based practices is the application of a ‘clinical care bundle’ for PPH management. A clinical care bundle is a set of discrete, evidence-based interventions, administered concurrently, or in rapid succession, to every eligible person, along with teamwork, communication, and cooperation. Once triggered, all bundle components must be delivered. The E-MOTIVE project aims to improve the detection and first response management of PPH through the implementation of the “E-MOTIVE” bundle, which consists of (1) Early PPH detection using a calibrated drape, (2) uterine Massage, (3) Oxytocic drugs, (4) Tranexamic acid, (5) Intra Venous fluids, and (6) genital tract Examination and escalation when necessary. The objective of this paper is to describe the protocol for the formative phase of the E-MOTIVE project, which aims to design an implementation strategy to support the uptake of this bundle into practice. Methods: We will use behaviour change and implementation science frameworks [e.g. capability, opportunity, motivation and behaviour (COM-B) and theoretical domains framework (TDF)] to guide data collection and analysis, in Kenya, Nigeria, South Africa, Sri Lanka, and Tanzania. There are four methodological components: qualitative inter views; surveys; systematic reviews; and design workshops. We will triangulate findings across data sources, participant groups, and countries to explore factors influencing current PPH detection and management, and potentially influencing E-MOTIVE bundle implementation. We will use these findings to develop potential strategies to improve implementation, which will be discussed and agreed with key stakeholders from each country in intervention design workshops. Discussion: This formative protocol outlines our strategy for the systematic development of the E-MOTIVE implementation strategy. This focus on implementation considers what it would take to support roll-out and implementation of the E-MOTIVE bundle. Our approach therefore aims to maximize internal validity in the trial alongside future scalability, and implementation of the E-MOTIVE bundle in routine practice, if proven to be effective. Trial registration: ClinicalTrials.gov: NCT04341662 Plain language summary Excessive bleeding after birth is the leading cause of maternal death globally. The World Health Organization (WHO) has recommended several treatment options for bleeding after birth. However, these treatments are not used regularly, or consistently for all women. A key underlying issue is that it is challenging for health workers to identify when women are bleeding too much, because measuring the amount of blood loss is difficult. Maternal health experts have proposed a new clinical ‘care bundle’ for caring for women with excessive bleeding after birth. A care bundle is a way to group together multiple treatments (e.g. 3–5 treatments). These treatments are then given to the woman at the same time, or one after another in quick succession, and supported by strategies to improve teamwork, communication, and cooperation. This is a research protocol for the preliminary phase of our study (“E-MOTIVE”), which means that it is a description of what we plan to do and how we plan to do it. The aim of our study is to develop a strategy for how we will test whether the E-MOTIVE bundle works through collaborative activities with midwives and doctors in five countries (Kenya, Nigeria, South Africa, Sri Lanka, and Tanzania) to develop a strategy for how we will test whether the E-MOTIVE bundle works. We plan to do this by conducting interviews and surveys with midwives and doctors, and reviewing other research conducted on PPH to understand what works in different settings. We will discuss our research findings in a workshop, with midwives and doctors in the study countries to co-create a strategy that will work for them, based on their needs and preferences