Maternal outcome in eclampsia at Harare Maternity Hospital.

A CAJM article on maternal mortality rates in Zimbabwe.Sub-Saharan Africa has one of the world’s highest maternal mortality ratios, estimated at 870/100 000 live births.1 Maternal mortality for the Greater Harare Maternity Unit (GHMU) was 370/100 000 live births in 1997 and eclampsia was responsible for 24.2% of maternal deaths.2 In the Greater Harare Maternity Unit (GHMU) the proportion of maternal deaths due to eclampsia has ranged between eight and 24% (Figure I). The proportion of maternal deaths due to eclampsia in similar settings ranges between 14 and 39%.3,4 Case fatality for eclampsia varies widely.3:5'9 There is need to reduce maternal mortality and interventions to achieve this reduction need to identify preventable causes of maternal death. Eclampsia is one such cause where case fatality can be reduced. We conducted a contemporaneous review of all clinical notes of women with a diagnosis of eclampsia managed in HMH from January 1997 to June 1998 with the purpose of identifying factors which adversely affected maternal outcome. Identification of risk factors for maternal death in eclamptic women was an essential step in the process of designing intervention strategies for reduction of maternal deaths from this preventable cause

Trends in maternal mortality for the Greater Harare Maternity Unit: 1976 to 1997.

A CAJM article on trends in maternal death in a Harare, Zimbabwe hospital.Objective: To determine the magnitude, trends and the main causes of maternal death for Harare Maternity Hospital (HMH) and thereby identify potential areas for interventions. Design: A descriptive retrospective analysis of maternal mortality data from the institution included in publications and recent annual reports. Setting: Department of Obstetrics and Gynaecology Greater Harare Maternity Unit, Zimbabwe. Main Outcome Measures: The trends in maternal mortality ratios (MMR) and the relative importance, of different causes of death between 1976 and 1997. Results: There was a decline in MMR between 1976 and the early 1980s but there has been a steady increase in MMR for Harare residents from 50/100 000 in 1988 to 224/100 000 in 1997. Sepsis has remained the leading cause of maternal death. There has been a significant increase in indirect deaths due to meningitis, tuberculosis and pneumonia where HIV infection is an underlying factor. Avoidable factors were identified at patient/ community, local health facility and at the tertiary hospital. There has been a decline in the quality of care in recent years. Conclusion: Maternal mortality for HMH is unacceptably high and could still be rising. HIV infection has contributed to the worsening picture. Interventions to improve access and quality of care at all levels could lead to significant 'reduction in maternal deaths

Challenges in school guidance and counselling services provisions for children with disabilities in Zimbabwean inclusive primary schools

The study investigated challenges in School Guidance and Counselling (SGC) services provisions for children with disabilities in Zimbabwean inclusive primary schools as a context for strategizing on overcoming them and proposing a model of School Guidance and Counselling services provisions for children with disabilities. The survey design, which was mainly quantitative in nature, was used. Self-administered questionnaires were used to collect data. Three hundred inclusive primary school administrators and three hundred school counsellors participated in the study. The Statistical Package for the Social Sciences, version 11.0 was used to analyze data. Frequency tables, ratios and Chi-square tests were computed. The study revealed that Zimbabwean inclusive primary school counsellors lacked training in School Guidance and Counselling and Special Needs Education. The school counsellors also lacked experience in teaching children with disabilities and the stakeholders had negative attitudes towards School Guidance and Counselling services provisions for children with disabilities. It was further revealed that inclusive primary schools lacked materials and supplies, time, finance, physical and curricular resources. The study revealed that there was no mandatory School Guidance and Counselling policy and legislation, clear mission statement, School Guidance and Counselling Framework, school counsellor certification requirements nor a School Guidance and Counselling national model. These facilities, together with Special Needs Education, experience in teaching children with disabilities and staff development, were found to positively impact on SGC services provisions for children with disabilities. School counsellors’ training in School Guidance and Counselling, advocacy on disabilities, stakeholders’ collaboration, passing mandatory School Guidance and Counselling policy and legislation, adequate budgetary and time allocation were seen as strategies to overcome challenges in SGC services provisions for children with disabilities in Zimbabwean inclusive primary schools. It was recommended that School Guidance and Counselling services provisions for children with disabilities in Zimbabwean inclusive primary schools would improve if there would be promulgation of mandatory School Guidance and Counselling policy and legislation, school counsellors’ training in School Guidance and Counselling, requisition of adequate resources and development of positive attitudes among stakeholders. Recommendations for further research were made.Inclusive EducationD. Ed. (Inclusive Education

Criteria-based audit on management of eclampsia patients at a tertiary hospital in Dar es Salaam, Tanzania

\ud Criteria-based audits have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the introduction of a criteria-based audit in a tertiary hospital in an African setting, assesses the quality of care among eclampsia patients and discusses possible interventions in order to improve the quality of care. We conducted a criteria based audit of 389 eclampsia patients admitted to Muhimbili National Hospital (MNH), Dar es Salaam Tanzania between April 14, 2006 and December 31, 2006. Cases were assessed using evidence-based criteria for appropriate care. Antepartum, intrapartum and postpartum eclampsia constituted 47%, 41% and 12% of the eclampsia cases respectively. Antepartum eclampsia was mostly (73%) preterm whereas the majority (71%) of postpartum eclampsia cases ware at term. The case fatality rate for eclampsia was 7.7%. Medical histories were incomplete, the majority (75%) of management plans were not reviewed by specialists in obstetrics, specialist doctors live far from the hospital and do not spend nights in hospital even when they are on duty, monitoring of patients on magnesium sulphate was inadequate, and important biochemical tests were not routinely done. Two thirds of the patient scheduled for caesarean section did not undergo surgery within agreed time. Potential areas for further improvement in quality of emergency care for eclampsia relate to standardizing management guidelines, greater involvement of specialists in the management of eclampsia and continued medical education on current management of eclampsia for junior staff.\u

Systematic review of effect of community-level interventions to reduce maternal mortality

<p>Abstract</p> <p>Background</p> <p>The objective was to provide a systematic review of the effectiveness of community-level interventions to reduce maternal mortality.</p> <p>Methods</p> <p>We searched published papers using Medline, Embase, Cochrane library, CINAHL, BNI, CAB ABSTRACTS, IBSS, Web of Science, LILACS and African Index Medicus from inception or at least 1982 to June 2006; searched unpublished works using National Research Register website, metaRegister and the WHO International Trial Registry portal. We hand searched major references.</p> <p>Selection criteria were maternity or childbearing age women, comparative study designs with concurrent controls, community-level interventions and maternal death as an outcome. We carried out study selection, data abstraction and quality assessment independently in duplicate.</p> <p>Results</p> <p>We found five cluster randomised controlled trials (RCT) and eight cohort studies of community-level interventions. We summarised results as odds ratios (OR) and confidence intervals (CI), combined using the Peto method for meta-analysis. Two high quality cluster RCTs, aimed at improving perinatal care practices, showed a reduction in maternal mortality reaching statistical significance (OR 0.62, 95% CI 0.39 to 0.98). Three equivalence RCTs of minimal goal-oriented versus usual antenatal care showed no difference in maternal mortality (1.09, 95% CI 0.53 to 2.25). The cohort studies were of low quality and did not contribute further evidence.</p> <p>Conclusion</p> <p>Community-level interventions of improved perinatal care practices can bring about a reduction in maternal mortality. This challenges the view that investment in such interventions is not worthwhile. Programmes to improve maternal mortality should be evaluated using randomised controlled techniques to generate further evidence.</p

The Potential of Medical Abortion to Reduce Maternal Mortality in Africa: What Benefits for Tanzania and Ethiopia?

BACKGROUND: Unsafe abortion is estimated to account for 13% of maternal mortality globally. Medical abortion is a safe alternative. METHODS: By estimating mortality risks for unsafe and medical abortion and childbirth for Tanzania and Ethiopia, we modelled changes in maternal mortality that are achievable if unsafe abortion were replaced by medical abortion. We selected Ethiopia and Tanzania because of their high maternal mortality ratios (MMRatios) and contrasting situations regarding health care provision and abortion legislation. We focused on misoprostol-only regimens due to the drug's low cost and accessibility. We included the impact of medical abortion on women who would otherwise choose unsafe abortion and on women with unwanted/mistimed pregnancies who would otherwise carry to term. RESULTS: Thousands of lives could be saved each year in each country by implementing medical abortion using misoprostol (2122 in Tanzania and 2551 in Ethiopia assuming coverage equals family planning services levels: 56% for Tanzania, 31% for Ethiopia). Changes in MMRatios would be less pronounced because the intervention would also affect national birth rates. CONCLUSIONS: This is the first analysis of impact of medical abortion provision which takes into account additional potential users other than those currently using unsafe abortion. Thousands of women's lives could be saved, but this may not be reflected in as substantial changes in MMRatios because of medical abortion's demographic impact. Therefore policy makers must be aware of the inability of some traditional measures of maternal mortality to detect the real benefits offered by such an intervention

Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change

The burden of maternal mortality in resource limited countries is still huge despite being at the top of the global public health agenda for over the last 20 years. We systematically reviewed the impacts of interventions on maternal health and factors for change in these countries. A systematic review was carried out using the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles published in the English language reporting on implementation of interventions, their impacts and underlying factors for maternal health in resource limited countries in the past 23 years were searched from PubMed, Popline, African Index Medicus, internet sources including reproductive health gateway and Google, hand-searching, reference lists and grey literature. Out of a total of 5084 articles resulting from the search only 58 qualified for systematic review. Programs integrating multiple interventions were more likely to have significant positive impacts on maternal outcomes. Training in emergency obstetric care (EmOC), placement of care providers, refurbishment of existing health facility infrastructure and improved supply of drugs, consumables and equipment for obstetric care were the most frequent interventions integrated in 52%-65% of all 54 reviewed programs. Statistically significant reduction of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the programs respectively. Births in EmOC facilities and caesarean section rates increased significantly in 71%-75% of programs using these indicators. Insufficient implementation of evidence-based interventions in resources limited countries was closely linked to a lack of national resources, leadership skills and end-users factors. This article presents a list of evidenced-based packages of interventions for maternal health, their impacts and factors for change in resource limited countries. It indicates that no single magic bullet intervention exists for reduction of maternal mortality and that all interventional programs should be integrated in order to bring significant changes. State leaders and key actors in the health sectors in these countries and the international community are proposed to translate the lessons learnt into actions and intensify efforts in order to achieve the goals set for maternal health

Which method is best for the induction of labour?: A systematic review, network meta-analysis and cost-effectiveness analysis

Background: More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour. Objective: To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups. Methods: We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group’s Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012–13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves. Results: We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 μg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 μg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed ‘best’. Few studies collected information on women’s views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective. Limitations: There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses. Conclusions: Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention

Trends in maternal mortality for the Greater Harare Maternity Unit: 1976 to 1997.

Objective: To determine the magnitude, trends and the main causes of maternal death for Harare Maternity Hospital (HMH) and thereby identify potential areas for interventions. Design: A descriptive retrospective analysis of maternal mortality data from the institution included in publications and recent annual reports. Setting: Department of Obstetrics and Gynaecology Greater Harare Maternity Unit, Zimbabwe. Main Outcome Measures: The trends in maternal mortality ratios (MMR) and the relative importance, of different causes of death between 1976 and 1997. Results: There was a decline in MMR between 1976 and the early 1980s but there has been a steady increase in MMR for Harare residents from 50/100 000 in 1988 to 224/100 000 in 1997. Sepsis has remained the leading cause of maternal death. There has been a significant increase in indirect deaths due to meningitis, tuberculosis and pneumonia where HIV infection is an underlying factor. Avoidable factors were identified at patient/ community, local health facility and at the tertiary hospital. There has been a decline in the quality of care in recent years. Conclusion: Maternal mortality for HMH is unacceptably high and could still be rising. HIV infection has contributed to the worsening picture. Interventions to improve access and quality of care at all levels could lead to significant 'reduction in maternal deaths