Maternal near-miss and death among women with postpartum haemorrhage: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the burden and health service events surrounding severe maternal outcomes (SMO) related to life-threatening postpartum haemorrhage (PPH) in Nigerian public tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth or puerperal complications. METHODS: All cases of SMO [maternal near miss (MNM) or maternal death (MD)] due to PPH were prospectively identified using WHO criteria over a 1-year period. MAIN OUTCOME MEASURES: Incidence of SMO, health service events, case fatality rate (CFR) and mortality index (MI: % of death/SMO). RESULTS: Postpartum haemorrhage occurred in 2087 (2.2%) of the 94 835 deliveries recorded during the study period. A total of 354 (0.3%) women had an SMO (103 MD; 251 MNM). It was the most frequent obstetric haemorrhagic complication across hospitals. PPH had the highest maternal mortality ratio (112/100 000 live births) and the recorded MI (29.1%) and CFR (4.9%) were second only to that of ruptured uterus. About 83% of women with SMO were admitted in a critical condition with over 50% being referred. MD was more likely when PPH led to neurological (80.8%), renal (73.5%) or respiratory (58.7%) organ dysfunction. Although the timing of life-saving interventions was not statistically different between the cases of MD and MNM, close to one-quarter of women who died received critical intervention at least 4 hours after diagnosis of life-threatening PPH. CONCLUSIONS: Postpartum haemorrhage was a significant contributor to obstetric haemorrhage and SMO in Nigerian hospitals. Emergency obstetric services should be enhanced at the lower levels of healthcare delivery to reduce avoidable deaths from PPH. FUNDING: The original research that generated the data for this secondary analysis, and the publication of this secondary analysis, was funded by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization. We have no other funding issue to declare for our study. TWEETABLE ABSTRACT: One hundred and three maternal deaths and 251 near-misses resulted from PPH in 42 Nigerian tertiary facilities in 1 year.

Utilization of the partograph in primary health care facilities in southwestern Nigeria.

OBJECTIVE: To assess knowledge about the partograph and its utilization among maternity care providers in primary health care in southwestern Nigeria. METHOD: Two hundred and seventy-five maternity care providers comprising of 64 CHEWS (23.3%), 74 Auxiliary midwives (26.9%), 123 Nurses/midwives (44.7%) and 14 medical doctors (5.1%) were interviewed in primary health centres and private hospitals in three states in southwestern Nigeria using a multi-stage sampling strategy. Knowledge about the partograph and assessment of labour were assessed with an interviewer-administered questionnaire. RESULTS: About a quarter of respondents, 75 (27.3%) had received prior training on the partograph. Only 25 (9.1%) reported that the partograpgh was available in their labour wards. Knowledge about the partograph was poor; only 18 (16.0%) of all respondents correctly mentioned at least one component part of the partograph, 21 (7.6%) correctly explained function of the alert line and 30 (10.9%) correctly explained function of the action line. Prior training significantly influenced knowledge about the partograph (gamma2 = 49.2; p < 0.05). Knowledge about assessment of labour was also poor: less than 50% of all respondents knew the normal duration of labour and just about 50% understood assessment for progress of labour. CONCLUSION: The partograpgh is not utilized for labour management in Nigeria. Knowledge about partograph and assessment during labour is grossly deficient. Findings suggest poor quality intrapartum care. Effective interventions to improve labour supervision skills and partograph utilization are urgently required.

Antenatal cardiotocography: experience in a Nigerian tertiary hospital.

OBJECTIVES: To compare selected perinatal characteristics between infants of mothers with reactive and non-reactive antenatal cardiotocography (non-stress test) results. PATIENTS AND METHODS: The medical records of all women who delivered within one week of a non-stress test were retrieved. The indication, test result, gestational age at delivery, Apgar score at 5 minutes, perinatal complications and neonatal ward admission were documented. RESULTS: One hundred and twelve women met study criteria among whom 51 tests were reactive and 61 were non-reactive. Post-datism, intra-uterine growth restriction, hypertensive disorders of pregnancy, and premature rupture of membranes were the commonest indications for the test. Post-datism was more commonly associated with a non-reactive test result. Women with non-reactive tests were almost twice as likely to be delivered by emergency Caesarean section, compared with women with reactive tests; although the test result did not significantly influence the mode of delivery. A non-reactive test was significantly associated with a higher perinatal mortality (p = 0.04). Although the reactive test was associated with a three-fold reduction in the incidence of low Apgar scores compared with the non-reactive test, this difference was not statistically significant (p = 0.18). A non-reactive test was significantly associated with small for gestational age infants (p = 0.01). CONCLUSIONS: Non-reactive non-stress test may be associated with higher perinatal mortality. When appropriately utilised, the test is a valuable tool for early detection of foetal compromise. Antenatal cardiotocography has a place in obstetric practice in low-resource settings for improving perinatal care.

Evaluation of criteria-based clinical audit in improving quality of obstetric care in a developing country hospital.

Study evaluated criteria-based clinical audit in measuring and improving quality of obstetric care for five life-threatening obstetric complications: obstetric haemorrhage, eclampsia, genital tract infections, obstructed labor and uterine rupture. Clinical management of 65 patients was audited using a 'before (Phase I) and after (Phase II)' audit cycle design using standard criteria. Following Phase I, areas in need of improvement were identified; mechanisms for improving quality of care were identified and implemented. Overall care of the complications improved significantly in obstetric haemorrhage (61 to 81%, p = 0.000), eclampsia (54.3 to 90%, p = 0.00), obstructed labour (81.7 to 93.5%, p < 0.001) and genital tract sepsis (66 to 85.2%, p < 0.01). Clinical monitoring, drug use, and urgent attention by senior medial staff also improved significantly after intervention. Criteria-based clinical audit is feasible and acceptable for improving management of life-threatening obstetric complications. Its application is recommended in health institutions in developing countries.

Knowledge and utilization of the partograph among obstetric care givers in south west Nigeria.

This cross-sectional study assessed knowledge and utilization of the partograph among health care workers in southwestern Nigeria. Respondents were selected by multi-stage sampling method from primary, secondary and tertiary levels of care. 719 respondents comprising of CHEWS--110 (15.3%), Auxiliary Nurses--148 (20.60%), Nurse/Midwives--365 (50.6%), Physicians--96 (13.4%) were selected from primary (38.2%), secondary (39.1%) and tertiary levels (22.7%). Only 32.3% used the partograph to monitor women in labour. Partograph use was reported significantly more frequently by respondents in tertiary level compared with respondents from primary/secondary levels of care (82.4% vs. 19.3%; X2 = 214.6, p < 0.0001). Only 37.3% of respondents who were predominantly from the tertiary level of care could correctly mention at least one component of the partograph (X2 = 139.1, p < 0.0001). The partograph is utilized mainly in tertiary health facilities; knowledge about the partograph is poor. Though affordable, the partograph is commonly not used to monitor the Nigerian woman in labour.

Knowledge and utilization of the partograph among obstetric care givers in South West Nigeria

This cross-sectional study assessed knowledge and utilization of the partograph among health care workers in southwestern Nigeria. Respondents were selected by multi-stage sampling method from primary; secondary and tertiary level care. 719 respondents comprising of CHEWS - 110 (15.3); Auxiliary Nurses - 148 (20.6); Nurse/Midwives - 365 (50.6); Physicians - 96 (13.4) were selected from primary (38.2); secondary (39.1) and tertiary levels (22.7). Only 32.3used the partograph to monitor women in labour. Partograph use was reported significantly more frequently by respondents in tertiary level compared with respondents from primary/secondary levels of care (82.4vs. 19.3; X2 = 214.6; p 0.0001). Only 37.3of respondents who were predominantly from the tertiary level of care could correctly mention at least one component of the partograph (X2 = 139.1; p 0.0001). The partograph is utilized mainly in tertiary health facilities; knowledge about the partograph is poor. Though affordable; the partograph is commonly not used to monitor the Nigerian woman in labour

Evaluation of criteria-based clinical audit in improving quality of obstetric care in a developing country hospital

Study evaluated criteria­based clinical audit in measuring and improving quality of obstetric care for five life-threatening obstetric complications: obstetric haemorrhage, eclampsia, genital tract infections, obstructed labor and uterine rupture. Clinical management of 65 patients was audited using a 'before (Phase I) and after (Phase II)' audit cycle design using standard criteria. Following Phase I, areas in need of improvement were identified; mechanisms for improving quality of care were identified and implemented. Overall care of the complications improved significantly in obstetric haemorrhage (61 to 81%, p = 0.000), eclampsia (54.3 to 90%, p=0.00), obstructed labour (81.7 to 93.5%, p<0.001) and genital tract sepsis (66 to 85.2%, p < 0.01). Clinical monitoring, drug use, and urgent attention by senior medial staff also improved significantly after intervention. Criteria-based clinical audit is feasible and acceptable for improving management of life-threatening obstetric complications. Its application is recommended in health institutions in developing countries (Afr J Reprod Health 2008; 12[3]:59-70)