Background Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. Method Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. Findings The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. Conclusion There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped.
Despite most Indonesian women now receiving antenatal care on the nationally recommended four occasions and being delivered by skilled birth attendants, the nation’s maternal mortality ratio (MMR) is estimated as 177 per 100,000 live births. Recent research in a rural district of Indonesia has indicated that poor service quality due to organizational and personnel factors is now a major determinant of this high MMR. The present research is an in-depth analysis of possible health service organizational and quality of care related causes of death among 30 women admitted to a peak referral hospital in a major Indonesian city. Despite their condition being complex or deteriorating, most of these women arrived at the hospital in a state where it was feasible to prevent death with good quality care. Poor application of protocols, poor information flow from frontline hospitals to the peak referral hospital, delays in emergency care, and delays in management of deteriorating patients were the main contributing factors to these deaths. Pyramidal referrals also contributed, as many women were initially referred to hospitals where their condition could not be effectively managed. While generic quality improvement measures, particularly training and monitoring for rigorous application of clinical protocols (including forward planning for deteriorating patients) will help improve the situation, the districts and hospitals need to develop capacity to assess their local situation. Unless local organisational factors, staff knowledge and skill, blood and blood product availability, and local reasons for delays in providing care are identified, it may not be possible to effectively reduce the adverse pregnancy outcomes.
Introduction : Vitamin D deficiency in utero or early neonatal life may have a major impact on children’s health. Little is known on vitamin D deficiency in pregnant women in Belgium, non on the impact of wearing head and/or body cover. Objectives : This was a preliminary exploration of the vitamin D status in pregnant women visiting the antenatal clinic in the Antwerp University Hospital. Method : From August 1 2009 until November 30 2009 we systematically determined 25-hydroxy vitamin D (25-OH vitamin D) in each blood sample taken from pregnant women visiting the antenatal clinic. We also registered the degree of head/body cover and inquired for intake of vitamin supplements. Results : Our population consisted of 171 women, mostly primiparous, of which 86% were not covered. The mean value of 25-OH vitamin D was 28 ng/ml. Non-covered women had a mean of 29,5 ± 12,2 (SD) ng/ml, the partially covered group had a mean of 17,2 ± 7,2 (SD) ng/ml and the completely covered group had a mean of 22,5 ± 12,9 (SD) ng/ml. The difference in serum concentrations between the 3 groups was statistically significant (Anova, p < 0,00001). There were significantly more covered than non-covered women with a vitamin D concentration lower than 30 ng/ml (OR6.2; 95% CI: 1,8-21,7; p < 0,05). There was no effect of gestational age, maternal age, gravidity, parity and intake of supplements on vitamin D levels. There was a siginificant seasonal effect from summer to fall, with Vitamine D levels lowering from August to November (linear regression, p < 0,05). Conclusion: Low vitamin D levels seem to be frequent and covered woman are at a higher risk of deficiency.
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