Background Annually, 2.6 million stillbirths occur worldwide, 98% in developing countries. It is crucial that we understand causes and contributing factors. Methods We conducted a systematic review of studies reporting factors associated with and cause(s) of stillbirth in low‐ and middle‐income countries (2000–13). Narrative synthesis to compare similarities and differences between studies with similar outcome categories. Main results A total of 142 studies with 2.1% from low‐income settings were investigated; most report on stillbirths occurring at health facility level. Definition of stillbirth varied; 10.6% of studies (mainly upper middle‐income countries) used a cut‐off point of ≥22 weeks of gestation and 32.4% (mainly lower income countries) used ≥28 weeks of gestation. Factors reported to be associated with stillbirth include poverty and lack of education, maternal age (>35 or <20 years), parity (1, ≥5), lack of antenatal care, prematurity, low birthweight, and previous stillbirth. The most frequently reported cause of stillbirth was maternal factors (8–50%) including syphilis, positive HIV status with low CD4 count, malaria and diabetes. Congenital anomalies are reported to account for 2.1–33.3% of stillbirths, placental causes (7.4–42%), asphyxia and birth trauma (3.1–25%), umbilical problems (2.9–33.3%), and amniotic and uterine factors (6.5–10.7%). Seven different classification systems were identified but applied in only 22% of studies that could have used a classification system. A high percentage of stillbirths remain ‘unclassified’ (3.8–57.4%). Conclusion To build capacity for perinatal death audit, clear guidelines and a suitable classification system to assign cause of death must be developed. Existing classification systems may need to be adapted. Better data and more data are urgently needed.
BackgroundAvailability of a Skilled Birth Attendant (SBA) during childbirth is a key indicator for MDG5 and a strategy for reducing maternal and neonatal mortality in Africa. There is limited information on how SBAs and their functions are defined. The aim of this study was to map the cadres of health providers considered SBAs in Sub Saharan Africa (SSA); to describe which signal functions of Essential Obstetric Care (EmOC) they perform and assess whether they are legislated to perform these functions.Methods and FindingsKey personnel in the Ministries of Health, teaching institutions, referral, regional and district hospitals completed structured questionnaires in nine SSA countries in 2009–2011. A total of 21 different cadres of health care providers (HCP) were reported to be SBA. Type and number of EmOC signal functions reported to be provided, varied substantially between cadres and countries. Parenteral antibiotics, uterotonic drugs and anticonvulsants were provided by most SBAs. Removal of retained products of conception and assisted vaginal delivery were the least provided signal functions. Except for the cadres of obstetricians, medical doctors and registered nurse-midwives, there was lack of clarity regarding signal functions reported to be performed and whether they were legislated to perform these. This was particularly for manual removal of placenta, removal of retained products and assisted vaginal delivery. In some countries, cadres not considered SBA performed deliveries and provided EmOC signal functions. In other settings, cadres reported to be SBA were able to but not legislated to perform key EmOC signal functions.ConclusionsComparison of cadres of HCPs reported to be SBA across countries is difficult because of lack of standardization in names, training, and functions performed. There is a need for countries to develop clear guidelines defining who is a SBA and which EmOC signal functions each cadre of HCP is expected to provide.
BackgroundIt is estimated that 18.5 million Caesarean Sections (CS) are conducted annually worldwide and about one-third of them are done without medical indications and described as “unnecessary”. Although developed countries account for most of the rise in the trend of unnecessary CS, more studies report a similar trend in developing countries, putting a strain on existing but limited healthcare resources, jeopardizing families' financial security and presenting a barrier to equitable universal coverage. We examined indications for CS in public hospitals of one district in Bangladesh and explored factors influencing decision to perform the procedure.MethodsRetrospective review of case notes of 530 women who had CS in 5 public hospitals in Thakurgaon District of Bangladesh. Key Informant Interviews (KII) with 18 service providers to explore factors associated with the decision to perform a CS.ResultsThe commonest recorded indications for CS were: previous CS (29.4%), fetal distress (15.7%), cephalo-pelvic disproportion (10.2%), prolonged obstructed labor (8.3%) and post-term dates (7.0%). The majority (68%) of CS were performed as emergency; mainly during daytime working hours. Previous CS and “post-term dates” were common indications for elective CS with “post dates” – the commonest indication for CS in primiparous women. 16.0% of all CS were conducted for cases where alternative forms of care might have been more appropriate. Providers reported not using protocols and evidence based guidelines even though these are available. Pressure from patients and relatives to deliver by CS strongly influenced decision making. External agents from private hospitals receive a financial reward for every CS performed and are present in public hospitals to “lobby” for CS.ConclusionFactors other than evidence based practice or the presence of a clear medical indication influence providers’ decision to perform both elective and emergency CS in public hospitals in Bangladesh.
BackgroundImproving the quality of care women receive during childbirth is as important as ensuring increased availability of care and numbers of healthcare providers. To be able to improve quality of care, it is important to understand what quality means for mothers as well as providers of care.Methods33 postnatal mothers and 10 healthcare providers from all 4 major hospitals in one district in Malawi were interviewed via 27 in-depth interviews and 2 focus group discussions. Data was transcribed and analysed using the thematic framework approach.ResultsPerceptions of quality of care differed substantially between care providers and postnatal mothers. For caregivers, characteristics of good quality care included availability of resources while for postnatal mothers positive relationships with their caregiver were important. Lack of autonomy and decision making power is a barrier to quality of care and it exists both at the level of the patient (mother) and at the level of her caregiver with healthcare providers unable to influence decisions made by more senior staff or management. Lack of autonomy was linked with the emerging themes of staff de-motivation, frustration, lack of empowerment to make change and resulting in a poor quality of care provided.ConclusionsCreating a reciprocal understanding of what good quality care comprises and the barriers as well as promoters of this should be the starting point for improving the quality of maternity care. A renewed focus is needed on improving communication, strengthening patient rights and autonomy whilst simultaneously motivating and enabling healthcare workers to provide comprehensive and inclusive quality of care.
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