Charles A. Ameh

Increased risk of maternal death among ethnic minority women in the UK

•  The most recent CEMACH report indicates that the UK maternal mortality rate has not fallen in recent years. •  This was attributed, in part, to increasing numbers of deaths amongst immigrant women. •  It is likely that newly‐arrived refugees are affected most.

Using the new ICD-MM classification system for attribution of cause of maternal death—a pilot study

Understanding the causes of and factors contributing to maternal deaths is critically important for development of interventions that reduce the global burden of maternal mortality and morbidity. The International Classification of Diseases—Maternal Mortality (ICD‐MM) classification of cause of death during pregnancy, childbirth and the puerperium was applied to data obtained from maternal death reviews (MDR) for 4558 maternal deaths from five countries in sub‐Saharan Africa. None of the data sets identified type of maternal death. Information obtained via MDR is generally sufficient to agree on classification of cause of death to the levels of type and group. The terms ‘underlying cause of death’ and ‘contributing conditions’ were used differently in different settings and a specific underlying cause of death was frequently not recorded. Application of ICD‐MM resulted in the reclassification of 3.1% (9/285) of cases to the group ‘unanticipated complications of management’, previously recorded as obstetric haemorrhage or unknown. An increased number of cases were assigned to the groups pregnancy‐related infection (5.6–10.2%) and pregnancies with abortive outcome (3.4–4.9%) when a clear distinction was made between women who died ‘with’ HIV/AIDS of obstetric causes (direct maternal death) and AIDS‐related indirect maternal deaths (group ‘non‐obstetric complications’). Similarly, anaemia and obstructed labour were more frequently identified as contributing factors than underlying cause of death. It would be helpful if MDR forms could have explicitly stated variables called: type, group and underlying cause of death as well as a dedicated section to the most frequently occurring contributing conditions recognised in that setting.

Knowledge and Skills of Healthcare Providers in Sub-Saharan Africa and Asia before and after Competency-Based Training in Emergency Obstetric and Early Newborn Care

Background Healthcare provider training in Emergency Obstetric and Newborn Care (EmOC&NC) is a component of 65% of intervention programs aimed at reducing maternal and newborn mortality and morbidity. It is important to evaluate the effectiveness of this. Methods We evaluated knowledge and skills among 5,939 healthcare providers before and after 3–5 days ‘skills and drills’ training in emergency obstetric and newborn care (EmOC&NC) conducted in 7 sub-Saharan Africa countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Zimbabwe) and 2 Asian countries (Bangladesh, Pakistan). Standardised assessments using multiple choice questions and objective structured clinical examination (OSCE) were used to measure change in knowledge and skills and the Improvement Ratio (IR) by cadre and by country. Linear regression was performed to identify variables associated with pre-training score and IR. Results 99.7% of healthcare providers improved their overall score with a median (IQR) increase of 10.0% (5.0% - 15.0%) for knowledge and 28.8% (23.1% - 35.1%) for skill. There were significant improvements in knowledge and skills for each cadre of healthcare provider and for each country (p<0.05). The mean IR was 56% for doctors, 50% for mid-level staff and nurse-midwives and 38% for nursing-aides. A teaching job, previous in-service training, and higher percentage of work-time spent providing maternity care were each associated with a higher pre-training score. Those with more than 11 years of experience in obstetrics had the lowest scores prior to training, with mean IRs 1.4% lower than for those with no more than 2 years of experience. The largest IR was for recognition and management of obstetric haemorrhage (49–70%) and the smallest for recognition and management of obstructed labour and use of the partograph (6–15%). Conclusions Short in-service EmOC&NC training was associated with improved knowledge and skills for all cadres of healthcare providers working in maternity wards in both sub-Saharan Africa and Asia. Additional support and training is needed for use of the partograph as a tool to monitor progress in labour. Further research is needed to assess if this is translated into improved service delivery.

‘Women and babies are dying but not of Ebola’: the effect of the Ebola virus epidemic on the availability, uptake and outcomes of maternal and newborn health services in Sierra Leone

Background We sought to determine the impact of the Ebola virus epidemic on the availability, uptake and outcome of routine maternity services in Sierra Leone. Methods The number of antenatal and postnatal visits, institutional births, availability of emergency obstetric care (EmOC), maternal deaths and stillbirths were assessed by month, by districts and by level of healthcare for 10 months during, and 12 months prior to, the Ebola virus disease (EVD) epidemic. All healthcare facilities designated to provide comprehensive (n=13) or basic (n=67) EmOC across the 13 districts of Sierra Leone were included. Results Preservice students were not deployed during the EVD epidemic. The number of healthcare providers in facilities remained constant (incidence rate ratio (IRR) 1.03, 95% CI 1.00 to 1.07). Availability of antibiotics, oxytocics, anticonvulsants, manual removal of placenta, removal of retained products of conception, blood transfusion and caesarean section were not affected by the EVD epidemic. Across Sierra Leone, following the onset of the EVD epidemic, there was a 18% decrease in the number of women attending for antenatal (IRR 0.82, 95% CI 0.79 to 0.84); 22% decrease in postnatal attendance (IRR 0.78, 95% CI 0.75 to 0.80) visits and 11% decrease in the number of women attending for birth at a healthcare facility (IRR 0.89, 95% CI 0.87 to 0.91). There was a corresponding 34% increase in the facility maternal mortality ratio (IRR 1.34, 95% CI 1.07 to 1.69) and 24% increase in the stillbirth rate (IRR 1.24, 95% CI 1.14 to 1.35). Conclusions During the EVD epidemic, fewer pregnant women accessed healthcare. For those who did, an increase in maternal mortality and stillbirth was observed. In the post-Ebola phase, ‘readiness’ (or not) of the global partners for large-scale epidemics has been the focus of debate. The level of functioning of the health system with regard to ability to continue to provide high-quality effective routine care needs more attention.

O477 STATUS OF EMERGENCY OBSTETRIC CARE IN SIX DEVELOPING COUNTRIES 5 YEARS BEFORE THE MDG TARGETS FOR MATERNAL AND NEWBORN HEALTH

Background Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population. Methods and Findings A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be <2%, the maternal Case Fatality Rate (CFR) for obstetric complications ranged from 2.0–9.3% and still birth (SB) rates ranged from 1.9–6.8%. Conclusions Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline.

Utilisation of maternal health services by adolescent mothers in Kenya: analysis of the demographic health survey 2008-2009.

Abstract Background: Many Kenyan adolescents die following pregnancy and childbirth complications. Maternal health services (MHS) utilisation is key to averting such poor outcomes. Our objectives were to understand the characteristics of adolescent mothers in Kenya, describe their MHS utilisation pattern and explore factors that influence this pattern. Methods: We collected demographic and MHS utilisation data of all 301 adolescent mothers aged 15–19 years included in the Kenya Demographic Health Survey 2008/2009 (KDHS). Descriptive statistics were used to characterise them and their MHS utilisation patterns. Bivariate and multivariate analyses were used to test associations between selected predictor variables and MHS utilisation. Findings: Eighty-six percent, 48% and 86% of adolescent mothers used ante-natal care (ANC), skilled birth attendance (SBA) and post-natal care (PNC), respectively. Adolescent mothers from the richest quintile were nine (CI=2.00–81.24, p=0.001) and seven (CI=3.22–16.22, p<0.001) times more likely to use ANC and SBA, respectively, compared to those from the poorest. Those with primary education were four (CI=1.68–9.64, p<0.001) and two (CI=0.97–4.81, p=0.043) times more likely to receive ANC and SBA, respectively, compared to uneducated mothers, with similar significant findings amongst their partners. Urban adolescent mothers were six (CI=1.89–32.45, p=0.001) and four (CI=2.00–6.20, p<0.001) times more likely to use ANC and SBA, respectively, compared to their rural counterparts. The odds of Maasai adolescent mothers using ANC was 90% (CI=0.02–0.93, p=0.010) lower than that of Kalenjin mothers. Conclusions: Adolescent MHS utilisation in Kenya is an inequality issue. To address this, focus should be on the poorest, least educated, rural-dwelling adolescent mothers living in the most disadvantaged communities.

Maternal health services utilisation by Kenyan adolescent mothers: Analysis of the Demographic Health Survey 2014

BACKGROUND Kenya has one of the highest adolescent fertility rates in East-Africa, estimated at 106 births per 1000 females aged 15-19years. In addition to promoting safe sexual behaviour, utilisation of maternal health services (MHS) is essential to prevent poor outcomes of pregnancy and childbirth. To ensure optimum planning, particularly in the context of the Sustainable Development Goals, this study assesses the current service utilisation patterns of Kenyan adolescent mothers and the factors that affect this utilisation. METHODS Using data from the recently published 2014 Kenya Demographic Health Survey, we collected demographic and utilisation data of all three MHSs (antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC)) of adolescent mothers aged 15-19years. We then conducted bivariate and multivariate analyses to test associations between selected demographic and service utilisation variables. RESULTS Our findings showed that half of Kenyan adolescent mothers have had their first birth by the age of 16. MHS utilisation rates amongst Kenyan adolescent mothers were 93%, 65%, 92% for ANC, SBA and PNC respectively. Mothers education, religion, ethnicity, place of residence, wealth quintile, mass media exposure, and geographical region were significant predictors for both ANC and SBA utilisation. Education level of partner was significant for ANC utilisation while parity was significant for both SBA and PNC. CONCLUSIONS Adolescent MHS utilisation is not optimum in Kenya. More work that includes affordable care provision, cultural re-orientation, targeted mass-media campaigns and male involvement in care need to be done with emphasis on the most disadvantaged areas.

Possible Reasons for Limited Effectiveness of a Skills and Drills Intervention to Improve Emergency Obstetric and Newborn Care

Youth centers, peer education, and one-off public meetings have generally been ineffective in facilitating young people’s access to sexual and reproductive health (SRH) services, changing their behaviors, or influencing social norms around adolescent SRH. Approaches that have been found to be effective when well implemented, such as comprehensive sexuality education and youth-friendly services, have tended to flounder as they have considerable implementation requirements that are seldom met. For adolescent SRH programs to be effective, we need substantial effort through coordinated and complementary approaches. Unproductive approaches should be abandoned, proven approaches should be implemented with adequate fidelity to those factors that ensure effectiveness, and new approaches should be explored, to include greater attention to prevention science, engagement of the private sector, and expanding access to a wider range of contraceptive methods that respond to adolescents’ needs.

Assessing value-for-money in maternal and newborn health

Responding to increasing demands to demonstrate value-for-money (VfM) for maternal and newborn health interventions, and in the absence of VfM analysis in peer-reviewed literature, this paper reviews VfM components and methods, critiques their applicability, strengths and weakness and proposes how VfM assessments can be improved. VfM comprises four components: economy, efficiency, effectiveness and cost-effectiveness. Both ‘economy’ and ‘efficiency’ can be assessed with detailed cost analysis utilising costs obtained from programme accounting data or generic cost databases. Before-and-after studies, case–control studies or randomised controlled trials can be used to assess ‘effectiveness’. To assess ‘cost-effectiveness’, cost-effectiveness analysis (CEA), cost-utility analysis (CUA), cost-benefit analysis (CBA) or social return on investment (SROI) analysis are applicable. Generally, costs can be obtained from programme accounting data or existing generic cost databases. As such ‘economy’ and ‘efficiency’ are relatively easy to assess. However, ‘effectiveness’ and ‘cost-effectiveness’ which require establishment of the counterfactual are more difficult to ascertain. Either a combination of CEA or CUA with tools for assessing other VfM components, or the independent use of CBA or SROI are alternative approaches proposed to strengthen VfM assessments. Cross-cutting themes such as equity, sustainability, scalability and cultural acceptability should also be assessed, as they provide critical contextual information for interpreting VfM assessments. To select an assessment approach, consideration should be given to the purpose, data availability, stakeholders requiring the findings and perspectives of programme beneficiaries. Implementers and researchers should work together to improve the quality of assessments. Standardisation around definitions, methodology and effectiveness measures to be assessed would help.

Building capacity for skilled birth attendance: An evaluation of the Maternal and Child Health Aides training programme in Sierra Leone

OBJECTIVE Maternal and Child Health Aides (MCH Aide) in Sierra Leone provide the majority of maternity services at primary care level. To formulate recommendations for improving the quality and scale-up of MCH Aides training an evaluation of all schools across Sierra Leone was undertaken. DESIGN Structured, direct observation of two randomly selected teaching sessions per school using pre-tested standardised review forms. Event sampling with random selection of timetabled sessions across all 14 MCH Aide Training Schools. SETTING All MCH Aide training schools across Sierra Leone. PARTICIPANTS Tutors across 14 MCH Aide training schools observed in August 2013. MEASUREMENTS Assessment of four key elements of teaching and learning: (1) teaching style, (2) use of visual aids, (3) teaching environment and (4) student involvement. FINDINGS In the majority of teaching schools there was over-crowding (11/14), lack of furniture and inconsistent electricity supply. Ten of 26 tutors used lesson plans and teaching was mostly tutor- rather than student-focused. Majority of tutors use a didactic approach rather than active learning methods. Teaching aides were rarely available (15% of lessons). Tutors were knowledgeable in their subject area and there was evidence of an excellent tutor-student relationship. KEY CONCLUSIONS Training for Maternal and Child health Aides relies on teacher focused didactic methods, which may hinder student learning. Teaching and learning within the schools needs to be enhanced by a combination of tutor development and improvements in the learning environment. IMPLICATIONS FOR PRACTICE Interventions to improve the quality of teaching are urgently needed and should include training on teaching techniques and student assessment for tutors, provision of audio visual equipment and teaching aides such as posters and mannequins. Monitoring and Evaluation of interventions is critical to be able to amend the programmes approach and address further challenges at an early stage.