Risk factors for maternal death in the highlands of rural northern Tanzania: a case-control study

<p>Abstract</p> <p>Background</p> <p>Tanzania has one of the highest maternal mortality ratios in sub-Saharan Africa. Due to the paucity of epidemiological information on maternal deaths, and the high maternal mortality estimates found earlier in the study area, our objective was to assess determinants of maternal deaths in a rural setting in the highlands of northern Tanzania by comparing the women dying of maternal causes with women from the same population who had attended antenatal clinics in the same time period.</p> <p>Methods</p> <p>A case-control study was done in two administrative divisions in Mbulu and Hanang districts in rural Tanzania. Forty-five cases of maternal death were found through a comprehensive community- and health-facility based study in 1995 and 1996, while 135 antenatal attendees from four antenatal clinics in the same population, geographical area, and time-span of 1995–96 served as controls. The cases and controls were compared using multivariate logistic regression analyses. Odds ratios, with 95% confidence intervals, were used as an approximation of relative risk, and were adjusted for place of residence (ward) and age. Further adjustment was done for potentially confounding variables.</p> <p>Results</p> <p>An increased risk of maternal deaths was found for women from 35–49 years versus 15–24 years (OR 4.0; 95%CI 1.5–10.6). Women from ethnic groups other than the two indigenous groups of the area had an increased risk of maternal death (OR 13.6; 95%CI 2.5–75.0). There was an increased risk when women or husbands adhered to traditional beliefs, (OR 2.1; 95%CI 1.0–4.5) and (OR 2.6; 95%CI 1.2–5.7), respectively. Women whose husbands did not have any formal education appeared to have an increased risk (OR 2.2; 95%CI 1.0–5.0).</p> <p>Conclusion</p> <p>Increasing maternal age, ethnic and religious affiliation, and low formal education of the husbands were associated with increased risk of maternal death. Increased attention needs to be given to formal education of both men and women. In addition, education of the male decision-makers should be given high priority in the community, especially in matters concerning pregnancy and delivery preparedness, since their choice greatly affects the survival of the pregnant and delivering women.</p

Making stillbirths count, making numbers talk - issues in data collection for stillbirths.

BACKGROUND: Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care. DISCUSSION: In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings. SUMMARY: Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems

Caesarean Section among Referred and Self-Referred Birthing Women: A Cohort Study from a Tertiary Hospital, Northeastern Tanzania.

The inequity in emergency obstetric care access in Tanzania is unsatisfactory. Despite an existing national obstetric referral system, many birthing women bypass referring facilities and go directly to higher-level care centres. We wanted to compare Caesarean section (CS) rates among women formally referred to a tertiary care centre versus self-referred women, and to assess the effect of referral status on adverse outcomes after CS. We used data from 21,011 deliveries, drawn from the birth registry of a tertiary hospital in northeastern Tanzania, during 2000-07. Referral status was categorized as self-referred if the woman had bypassed or not accessed referral, or formally-referred if referred by a health worker. Because CS indications were insufficiently registered, we applied the Ten-Group Classification System to determine the CS rate by obstetric group and referral status. Associations between referral status and adverse outcomes after CS delivery were analysed using multiple regression models. Outcome measures were CS, maternal death, obstetric haemorrhage ≥ 750 mL, postpartum stay > 9 days, neonatal death, Apgar score < 7 at 5 min and neonatal ward transfer. Referral status contributed substantially to the CS rate, which was 55.0% in formally-referred and 26.9% in self-referred birthing women. In both groups, term nulliparous singleton cephalic pregnancies and women with previous scar(s) constituted two thirds of CS deliveries. Low Apgar score (adjusted OR 1.42, 95% CI 1.09-1.86) and neonatal ward transfer (adjusted OR 1.18, 95% CI 1.04-1.35) were significantly associated with formal referral. Early neonatal death rates after CS were 1.6% in babies of formally-referred versus 1.2% in babies of self-referred birthing women, a non-significant difference after adjusting for confounding factors (adjusted OR 1.37, 95% CI 0.87-2.16). Absolute neonatal death rates were > 2% after CS in breech, multiple gestation and preterm deliveries in both referral groups. Women referred for delivery had higher CS rates and poorer neonatal outcomes, suggesting that the formal referral system successfully identifies high-risk birth, although low volume suggests underutilization. High absolute rates of post-CS adverse outcomes among breech, multiple gestation and preterm deliveries suggest the need to target self-referred birthing women for earlier professional intrapartum care

Kan medisinske fødselsregistre være til nytte i utviklingsland?

Med utgangspunkt i mangeårige erfaringer som konsulent for Medisinsk fødselsregister og medlemskap i registerets rådgivende utvalg beskriver jeg etableringen av et medisinsk fødselsregister i et utviklingsland, Tanzania. Kilimanjaro Christian Medical Centre (KCMC) er et universitetssykehus, der hver eneste fødselsiden juli 2000 er blitt registrert elektronisk, med samtykke fra moren. Både mødredødeligheten og den perinatale dødeligheten i Tanzania er i størrelsesorden minst tretti ganger høyere enn i Norge. Tanken er at et register som regelmessig rapporterer viktige hendelser under fødslene, vil skjerpe årvåkenheten og bidratil bedre kvalitet av fødselshjelpen. Samtidig vil registeret være en kilde til forskning i feltet reproduktiv helse. Artikkelen omtaler oppbyggingen og driften av registeret, problemer som måtte løses underveis, og hvilken mulighet det er for å utvide dekningen til å gjelde alle fødeinstitusjonene i Kilimanjaroregionen.Det vil i tilfelle være et langt skritt i retning av et populasjonsbasert register. Inntil videre er muligheten til å inkludere hjemmefødsler (ca. 20 prosent i regionen) begrenset

Keisersnitt gjennom 40 år. Overvåking ved hjelp av Medisinsk fødselsregister

Denne oversiktsartikkelen beskriver den store økningen i hyppigheten av keisersnitt de siste 40 år, med fokus på den rollen Medisinsk fødselsregister har spilt for overvåking og analyser av mulige årsaker. Fødselsregisteret har også vært aktør i flere internasjonale prosjekter. I Norge har keisersnittratene økt fra 1,8 prosent i 1967 til 16,4 prosent i 2005. I Norden ligger Danmark nå høyest med over 20 prosent i 2004. Grensene for medisinske indikasjoner er tøyet betraktelig, og nyere teknologi (fosterblodanalyser og kardiotokografer) har gitt nye indikasjoner. I tillegg gjøres nå mellom fem og ti prosent av keisersnittene i Norge på mors ønske eller med tynn medisinsk begrunnelse. I Norge og flere andre land har forsøk på å snu trenden med økende bruk av keisersnitt ikke eller bare midlertidig hatt ønsket effek