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.

Maternal death review (MDR) is an accepted process that is implemented across Malawi and 'underlying cause of death' is assigned by healthcare providers using a standard MDR form. Mixed-methods approach. Key informant interviews with eight stakeholders involved in MDR. Secondary analysis of MDR forms for 54 maternal deaths. Comparison of assigned cause of death by healthcare providers conducting MDR at health facility level with cause assigned by researchers using the International Classification of Diseases Maternal Mortality (ICD-MM) classification. MDR teams, analysts and policymakers reported facing challenges in completing the forms, analysing and using information. The concepts of underlying (primary) and contributing (secondary) causes of death are often misunderstood. Healthcare providers using only MDR forms reported cause of death as non-obstetric complications in 39.6% and pregnancy-related infection in 11.3% of cases. For 30.2% of cases, no clear clinical cause of death was recorded. The most commonly assigned underlying cause of death using ICD-MM was obstetric haemorrhage (32.1%), non-obstetric complications (24.5%) and pregnancy-related infection (22.6%). There was poor agreement between cause(s) of maternal death assigned by healthcare providers in the field and trained researchers using the new ICD-MM classification (j statistic; 0.219). The majority of cases could be reclassified using the ICD-MM and this provided a more specific cause of death. A more structured and user-friendly MDR form is required. Accurate classification of cause of death is important. Dissemination of, and training in the use of the new ICD-MM classification system will be helpful to healthcare providers conducting MDR in Malawi.Keywords ICD-MM, maternal death classification, maternal death reviews, maternal deaths.

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Changing the role of the TBA to support facility-based delivery is feasible and acceptable. Further research is needed to see whether this is replicable and can be scaled-up.

Background:The purpose of this study was to assess the attitudes of maternal health care providers to pain relief during labor in Zaria, Nigeria.Methods:This was a multicenter, collaborative, cross-sectional pilot study of provider perspectives concerning pain relief during labor. A structured, self-administered, questionnaire was completed by 95 consenting maternal health care providers at three high-volume facilities in Zaria, an ancient northern Nigerian city. Descriptive statistics was performed on the data.Results:Most respondents (94.8%) agreed that pain relief is needed during labor. Only 2.1% of respondents were undecided about the provision of pain relief during labor and 3.2% were of the opinion that pain relief was not necessary during labor. Most respondents (93.7%) had attended a woman in labor in the 4 weeks preceding the survey. Of these, 56.8% had counseled a parturient in labor. Most of the counseling (42.1%) took place during labor. Less than half of the respondents (48.4%) had administered pain relief in labor in the preceding 4 weeks and systemic opioids was the most commonly form of pain relief. Among the respondents who did not offer pain relief agents in labor, the majority (54.5%) had no reason for not offering it. Unavailability of methods, inability to afford the cost of pain relief, lack of knowledge and skills, as well as lack of essential equipment to provide the procedure were also given by respondents as reasons for not offering pain relief.Conclusion:Even though maternal health care providers in this environment have a positive attitude to pain relief in labor, most women go through labor without the benefit of analgesia. There exists a gap between provider attitudes to pain relief in labor and practice of the same, with many providers having no genuine reason(s) for not offering pain relief to their clients during labor. Providers need to align their practice to their attitudes, and need to be helped to do this through training as well as enhancing their ability to think critically about their practice.

Background: Operative vaginal deliveries are frequent features of obstetrics practice in tertiary levels of care even in developing countries. It is essential to review these practices in order to assess their benefi ts or otherwise to safe motherhood in resource limited settings Study design: Labor records on operative vaginal delivery cases and matched controls who had spontaneous vaginal deliveries between January 1997 and December 2001 at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, were analyzed with respect to mode of delivery, indication for operative vaginal delivery, anesthesia use, fetal 5-min Apgar score, birth weight, fetal, and maternal complications. Results: Of 7,327 deliveries at the center in the study period, 262 (3.6%) were by operative vaginal deliveries. Forceps delivery was most frequently performed (55.7%), while vacuum delivery was found to be in increased use (38.2%). Embryotomy procedures were performed selectively (6.1%). Operative vaginal deliveries were more commonly employed on primigravida (78.6%) compared to multiparas and the most common indication was delayed second stage of labor. Forcep-and vacuum-assisted deliveries were both associated with maternal and newborn complications. There was no signifi cant difference in the use of anesthesia between forceps and vacuum deliveries. Conclusion: Operative vaginal delivery rates in this center are comparable to other centers as are the possible complications. Making these procedures safer will improve safe motherhood in settings where there are performed.

Background:Pain relief in labor remains a hot topic and these debates get louder by the day as more women become aware of their rights to better quality of care in labor. This study was conceived in a background where the practice of pain relief in labor is evolving and where women are seeking to fulfill their need for pain-free labor.Objective:To investigate the knowledge, utilization and preferences of methods of pain relief in labor by expectant mothers in order to design a labor analgesia program.Materials and Methods:A questionnaire-based descriptive study involving 124 antenatal clients in a teaching hospital over a 1 week period. Descriptive statistics were carried out using SPSS for windows version 17.Results:The mean age of clients was 28.8 years (standard deviation = 5.17) with median parity of two and mean gestational age was 31.5 weeks. Majority of the respondents (47.9%) were of Hausa/Fulani ethnicity and 97.6% had primary school level education. Majority (87.3%) had heard about pain relief methods with the hospital being the source in 79% of cases. The most common method ever heard about was epidural analgesia (69.4%). Only 4% (n = 5) of respondents remembered ever using any form of pain relief agent in labor, of which three received parenteral opioids. In their current pregnancies, 45.2% consented to the use of pain relief in labor; of which, epidural analgesia was preferred by 92.9% (n = 52). Fear of adverse effects on self and infants were cited as reasons for non-consent by some respondents while others had no reason.Conclusion:The study reveals a high awareness of pain relief methods which is not matched by utilization and low knowledge about side-effects, although fear of side-effects is a factor for under-utilization. There is a need to educate adequately as well provide high quality pain relief services in labor in order to dispel with myths, misconceptions and fears associated with the use of methods of pain relief in labor.

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