Maternal mortality in the rural Gambia, a qualitative study on access to emergency obstetric care

BACKGROUND: Maternal mortality is the vital indicator with the greatest disparity between developed and developing countries. The challenging nature of measuring maternal mortality has made it necessary to perform an action-oriented means of gathering information on where, how and why deaths are occurring; what kinds of action are needed and have been taken. A maternal death review is an in-depth investigation of the causes and circumstances surrounding maternal deaths. The objectives of the present study were to describe the socio-cultural and health service factors associated with maternal deaths in rural Gambia. METHODS: We reviewed the cases of 42 maternal deaths of women who actually tried to reach or have reached health care services. A verbal autopsy technique was applied for 32 of the cases. Key people who had witnessed any stage during the process leading to death were interviewed. Health care staff who participated in the provision of care to the deceased was also interviewed. All interviews were tape recorded and analyzed by using a grounded theory approach. The standard WHO definition of maternal deaths was used. RESULTS: The length of time in delay within each phase of the model was estimated from the moment the woman, her family or health care providers realized that there was a complication until the decision to seeking or implementing care was made. The following items evolved as important: underestimation of the severity of the complication, bad experience with the health care system, delay in reaching an appropriate medical facility, lack of transportation, prolonged transportation, seeking care at more than one medical facility and delay in receiving prompt and appropriate care after reaching the hospital. CONCLUSION: Women do seek access to care for obstetric emergencies, but because of a variety of problems encountered, appropriate care is often delayed. Disorganized health care with lack of prompt response to emergencies is a major factor contributing to a continued high mortality rate

Availability and quality of emergency obstetric care in Gambia's main referral hospital: women-users' testimonies

<p>Abstract</p> <p>Background</p> <p>Reduction of maternal mortality ratio by two-thirds by 2015 is an international development goal with unrestricted access to high quality emergency obstetric care services promoted towards the attainment of that goal. The objective of this qualitative study was to assess the availability and quality of emergency obstetric care services in Gambia's main referral hospital.</p> <p>Methods</p> <p>From weekend admissions a group of 30 women treated for different acute obstetric conditions including five main diagnostic groups: hemorrhage, hypertensive disorders, dystocia, sepsis and anemia were purposively selected. In-depth interviews with the women were carried out at their homes within two weeks of discharge.</p> <p>Results</p> <p>Substantial difficulties in obtaining emergency obstetric care were uncovered. Health system inadequacies including lack of blood for transfusion, shortage of essential medicines especially antihypertensive drugs considerably hindered timely and adequate treatment for obstetric emergencies. Such inadequacies also inflated the treatment costs to between 5 and 18 times more than standard fees. Blood transfusion and hypertensive treatment were associated with the largest costs.</p> <p>Conclusion</p> <p>The deficiencies in the availability of life-saving interventions identified are manifestations of inadequate funding for maternal health services. Substantial increase in funding for maternal health services is therefore warranted towards effective implementation of emergency obstetric care package in The Gambia.</p

Why are women dying when they reach hospital on time? A systematic review of the 'third delay'.

BACKGROUND: The 'three delays model' attempts to explain delays in women accessing emergency obstetric care as the result of: 1) decision-making, 2) accessing services and 3) receipt of appropriate care once a health facility is reached. The third delay, although under-researched, is likely to be a source of considerable inequity in access to emergency obstetric care in developing countries. The aim of this systematic review was to identify and categorise specific facility-level barriers to the provision of evidence-based maternal health care in developing countries. METHODS AND FINDINGS: Five electronic databases were systematically searched using a 4-way strategy that combined search terms related to: 1) maternal health care; 2) maternity units; 3) barriers, and 4) developing countries. Forty-three original research articles were eligible to be included in the review. Thirty-two barriers to the receipt of timely and appropriate obstetric care at the facility level were identified and categorised into six emerging themes (Drugs and equipment; Policy and guidelines; Human resources; Facility infrastructure; Patient-related and Referral-related). Two investigators independently recorded the frequency with which barriers relating to the third delay were reported in the literature. The most commonly cited barriers were inadequate training/skills mix (86%); drug procurement/logistics problems (65%); staff shortages (60%); lack of equipment (51%) and low staff motivation (44%). CONCLUSIONS: This review highlights how a focus on patient-side delays in the decision to seek care can conceal the fact that many health facilities in the developing world are still chronically under-resourced and unable to cope effectively with serious obstetric complications. We stress the importance of addressing supply-side barriers alongside demand-side factors if further reductions in maternal mortality are to be achieved

West German Study PlanB Trial: Adjuvant Four Cycles of Epirubicin and Cyclophosphamide Plus Docetaxel Versus Six Cycles of Docetaxel and Cyclophosphamide in HER2-Negative Early Breast Cancer

PURPOSE The West German Study Group PlanB trial evaluated an anthracycline-free chemotherapy standard (six cycles of docetaxel and cyclophosphamide [TC]) in the routine treatment of human epidermal growth factor receptor 2-negative early breast cancer (EBC). PATIENTS AND METHODS Patients with pT1 to pT4c, all pN+, and pN0/high-risk EBC were eligible. High-risk pN0 was defined by one or more of the following: pT greater than 2, grade 2 to 3, high urokinase-type plasminogen activator/plasminogen activator inhibitor-1, hormone receptor (HR) negativity, and less than 35 years of age. After an early amendment, all HR-positive tumors underwent recurrence score (RS) testing, with chemotherapy omission recommended in RS less than or equal to 11 pN0 to pN1 disease. Patients were randomly assigned to four cycles of epirubicin (E)(90)/cyclophoshamide (C)(600) followed by four cycles of docetaxel (T)(100) or six cycles of T75C600 (administered once every 3 weeks). The primary end point was disease-free survival (DFS); secondary end points were overall survival (OS) and safety. The protocol specified P = .05 for a noninferiority margin of 4.4% for all patients combined. RESULT Of the 3,198 registered patients, 348 (RS <= 11) omitted chemotherapy, and 401 were not randomly assigned. The intention-to-treat population included 2,449 patients (1,227 EC-T v 1,222 TC: postmenopausal, 62.2% v60.8%; pNO, 58.2% v59.5%; pT1, 57.6% v52.3%; HR positive, 81.4% v82.2%; RS greater than 25 [in H.R-positive patients], 26.2% v 27.5%). Within the safety population (1,167 v 1,178 patients), 87.5% v 93.0% completed therapy. After a 60-month median follow-up, 5-year outcomes were similar in the EC-T and TC arms (DFS, 89.6% [95% CI, 87.9% to 91.5%] v89.9% [95% CI, 88.1% to 91.8%]; OS, 94.5% [95% CI, 93.1% to 95.9%] v94.7% [95% CI, 93.3% to 96.1%]). The DFS difference was within the noninferiority margin of the original trial design. Five treatment-related deaths were reported for TC (one for EC-T), despite a trend toward more-severe adverse events in the latter. Interaction analysis revealed no predictive trends with respect to key factors, including triple-negative, luminal A/B-like, pN, age, and RS status. CONCLUSION In the West German Study Group PlanB trial, 5-year outcomes for TC and EC-T were equally excellent. Six cycles of TC is an effective/safe option in human epidermal growth factor receptor 2-negative EBC with pN0 high genomic risk or pN1 EBC with genomically intermediate- to high-risk disease. (C) 2019 by American Society of Clinical Oncolog