A retrospective review of facility-level obstetric complications and stillbirths in southern Haiti, 2013 – 2016

[ABSTRACT]. Objective. To assess the incidence of obstetric complications—eclampsia, dystocia, cesarean section, postpartum hemorrhage, and stillbirths—in hospitals in southern Haiti in 2013 – 2016 and to discuss implications for improvements to the surveillance of birth outcomes. Methods. This was a cross-sectional, retrospective study of data for 32 442 deliveries recorded in 2013 – 2016 by the Integrated Monitoring, Evaluation, and Surveillance System for facilities across three departments and one high-volume hospital in southern Haiti. Annual incidence rates of eclampsia, dystocia, cesarean section, postpartum hemorrhage, and stillbirths (both macerated and fresh) were calculated. Results. The incidence of eclampsia in the study sample was 2% – 3% and of dystocia approximately 5%, comparable to elsewhere in Haiti and other low-income countries. Cesarean delivery rates averaged about 15% annually. Postpartum hemorrhage rates were lower than published data from similar settings. Stillbirth rates ranged from 30 – 62 per 1 000 births at all facilities, higher than previously recorded by the country’s population surveys. The rates of macerated stillbirths were remarkably high, close to 50% of total stillbirths, indicating severe delays in seeking or receiving emergency obstetric care. Conclusions. This study provides important benchmarks for the current burden of preventable labor- and delivery-related complications in Haiti. Surveillance data suggest an urgent need for the management of hypertensive disorders during pregnancy, timely cesarean sections for dystocia, and management and treatment of postpartum hemorrhage in Haiti. Frequent data reviews may help address facility-specific bottlenecks.

[RESUMEN]. Objetivo. Evaluar la incidencia de las complicaciones obstétricas, como la eclampsia, la distocia, las cesáreas, la hemorragia posparto y la mortinatalidad, en los hospitales del sur de Haití en el período comprendido entre los años 2013 y 2016, y analizar las implicaciones para realizar mejoras en la vigilancia de los resultados perinatales. Métodos. Se trata de un estudio transversal y retrospectivo de los datos de 32 442 partos registrados en el período 2013-2016 mediante el sistema integrado de seguimiento, evaluación y vigilancia para establecimientos en tres departamentos y un hospital de gran actividad en el sur de Haití. Se calcularon las tasas de incidencia anuales de eclampsia, distocia, cesáreas y hemorragia posparto, así como de mortinatalidad (mortinatos macerados y frescos). Resultados. La incidencia de eclampsia en la muestra de estudio fue de entre 2% y 3% y de distocia, de aproximadamente 5%, equiparable a cualquier lugar en Haití y otros países de ingresos bajos. Las tasas promedio de parto por cesárea se aproximaron al 15% anual. Las tasas de hemorragia posparto fueron inferiores a los datos publicados sobre entornos similares. Las tasas de mortinatalidad comprendieron entre 30 y 62 por 1 000 nacimientos en la totalidad de establecimientos, un resultado mayor al que registrado con anterioridad en las encuestas de población del país. Las tasas de mortinatos macerados fueron notablemente elevadas, cerca de 50% de la mortinatalidad total, lo que pone de manifiesto retrasos graves a la hora de solicitar u obtener atención obstétrica de urgencia. Conclusiones. Este estudio ofrece puntos de referencia relevantes para la carga actual de complicaciones prevenibles del embarazo y el parto en Haití. Los datos de vigilancia indican que existe una urgente necesidad de tratamiento de los trastornos hipertensivos durante el embarazo, de cesáreas por distocia a tiempo, y de atención y tratamiento de la hemorragia posparto en Haití. Para abordar los obstáculos propios de los establecimientos puede ser útil realizar análisis frecuentes de los datos.

[RESUMO]. Objetivo. Avaliar a incidência de complicações obstétricas – eclâmpsias, distocias, cesarianas, hemorragias pós-parto e natimortos – em hospitais na região Sul do Haiti no período de 2013 a 2016 e discutir as implicações para melhorar a vigilância dos resultados dos partos. Métodos. Este foi um estudo transversal, retrospectivo, com dados de 32 442 partos registrados pelo Sistema Integrado de Monitoramento, Avaliação e Vigilância para estabelecimentos de saúde situados em três divisões político-administrativas (denominadas de departamentos) e um hospital de alto volume, todos situados na região Sul do Haiti, no período de 2013 a 2016. Foram calculadas as taxas anuais de incidência de eclâmpsias, distocias, cesarianas, hemorragias pós-parto e natimortos (macerados e frescos). Resultados. Na amostra do estudo, a taxa de incidência de eclâmpsias foi de 2 a 3%, e a de partos distócicos de aproximadamente 5%, comparáveis com as de outras localidades no Haiti e com outros países de baixa renda; as cesarianas apresentaram média anual de aproximadamente 15%; as taxas de hemorragia pós-parto foram menores que as publicadas sobre estabelecimentos similares. Em todos os estabelecimentos, as taxas de partos de natimortos variaram de 30 a 62 por 1 000 nascimentos, sendo mais altas que as anteriormente registradas pelos levantamentos populacionais do país. As taxas de natimortos macerados foram excepcionalmente altas, aproximadamente 50% do total de partos de natimortos, o que indica que há graves atrasos, seja na procura por atenção obstétrica de emergência ou no recebimento dessa atenção. Conclusões. Esse estudo fornece importantes parâmetros para determinar a atual carga de complicações passíveis de prevenção relacionadas com o trabalho de parto e com o parto propriamente dito no Haiti. Os dados de vigilância sugerem que, no Haiti, há uma necessidade urgente de manejar distúrbios hipertensivos durante a gestação, realizar cesarianas em tempo oportuno nos casos de distocias e manejar e tratar hemorragias pós-parto. Revisões frequentes dos dados podem ajudar a identificar os gargalos específicos de cada estabelecimento.

A retrospective review of facility-level obstetric complications and stillbirths in southern Haiti, 2013 - 2016.

OBJECTIVE: To assess the incidence of obstetric complications-eclampsia, dystocia, cesarean section, postpartum hemorrhage, and stillbirths-in hospitals in southern Haiti in 2013 - 2016 and to discuss implications for improvements to the surveillance of birth outcomes. METHODS: This was a cross-sectional, retrospective study of data for 32 442 deliveries recorded in 2013 - 2016 by the Integrated Monitoring, Evaluation, and Surveillance System for facilities across three departments and one high-volume hospital in southern Haiti. Annual incidence rates of eclampsia, dystocia, cesarean section, postpartum hemorrhage, and stillbirths (both macerated and fresh) were calculated. RESULTS: The incidence of eclampsia in the study sample was 2% - 3% and of dystocia approximately 5%, comparable to elsewhere in Haiti and other low-income countries. Cesarean delivery rates averaged about 15% annually. Postpartum hemorrhage rates were lower than published data from similar settings. Stillbirth rates ranged from 30 - 62 per 1 000 births at all facilities, higher than previously recorded by the country's population surveys. The rates of macerated stillbirths were remarkably high, close to 50% of total stillbirths, indicating severe delays in seeking or receiving emergency obstetric care. CONCLUSIONS: This study provides important benchmarks for the current burden of preventable labor- and delivery-related complications in Haiti. Surveillance data suggest an urgent need for the management of hypertensive disorders during pregnancy, timely cesarean sections for dystocia, and management and treatment of postpartum hemorrhage in Haiti. Frequent data reviews may help address facility-specific bottlenecks.

Retention in Care among HIV-Infected Pregnant Women in Haiti with PMTCT Option B.

Background. Preventing mother-to-child transmission of HIV relies on engagement in care during the prenatal, peripartum, and postpartum periods. Under PMTCT Option B, pregnant women with elevated CD4 counts are provided with antiretroviral prophylaxis until cessation of breastfeeding. Methods. Retrospective analysis of retention in care among HIV-infected pregnant women in Haiti was performed. Logistic regression was used to identify risk factors associated with loss to follow-up (LFU) defined as no medical visit for at least 6 months and Kaplan-Meier curves were created to show LFU timing. Results. Women in the cohort had 463 pregnancies between 2009 and 2012 with retention rates of 80% at delivery, 67% at one year, and 59% at 2 years. Among those who were LFU, the highest risk period was during pregnancy (60%) or shortly afterwards (24.4% by 12 months). Never starting on antiretroviral therapy (aRR 2.29, 95% CI 1.4-3.8) was associated with loss to follow-up. Conclusions. Loss to follow-up during and after pregnancy was common in HIV-infected women in Haiti under PMTCT Option B. Since sociodemographic factors and distance from home to facility did not predict LFU, future work should elicit and address barriers to retention at the initial prenatal care visit in all women. Better tracking systems to capture engagement in care in the wider network are needed.