Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study

Abstract

BackgroundTo study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital.MethodsA criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249).ResultsThe overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital’s registers. The majority of singletons had birthweight ≥2000 g (n = 139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75–315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06–3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68–5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70–12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect.ConclusionsIntrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities.Trial registrationThis is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org (NCT02318420, 4th November 2014).Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-1142-2) contains supplementary material, which is available to authorized users.

Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of Zanzibar: a quasi‐experimental pre‐post study (The PartoMa study)

“…Therefore, a sub‐analysis of fetal heart rate (FHR) on admission was conducted on all available case files of singleton stillbirths in the intervention months to approximate the proportion with positive FHR on admission (intrahospital stillbirths). This was previously done for the baseline . Notably, classification of fresh and macerated stillbirths was earlier found unreliable and therefore not applied .…”

Factors affecting effective ventilation during newborn resuscitation: a qualitative study among midwives in rural Tanzania

“…Motivating health-care workers in resource-poor settings can sometimes be a challenge. Nevertheless, supportive leadership and effective management at hospital level has been shown to modify the impact of resource shortfalls and foster good working relations between cadres [26,29]. …”

Delphi consensus statement on intrapartum fetal monitoring in low‐resource settings

“…A rapid, low‐cost, low‐technology triage algorithm based on the findings of risk assessment and physical examination—for example, an adapted version of the Intelligent Structured Intermittent Auscultation framework —to triage laboring women into appropriate levels of fetal monitoring in low‐resource settings might support the implementation of these recommendations. Furthermore, IA on admission is a simple quality‐of‐care indicator to evaluate and improve intra‐hospital care …”

“…Almost all perinatal deaths occur in low‐ and middle‐income countries (LMICs), and half occur intrapartum . The daily reality of many low‐resource health facilities impedes timely and high‐quality labor care . On admission, women have unknown or insufficiently known risk status owing to inadequate prenatal care and suboptimal assessment at first contact with a skilled birth attendant .…”

“…On admission, women have unknown or insufficiently known risk status owing to inadequate prenatal care and suboptimal assessment at first contact with a skilled birth attendant . During labor, women receive suboptimal support, including poor monitoring of their babies, who may die unnoticed . Fetal monitoring may provide crucial information on the adequacy of fetal oxygenation during labor for timely and appropriate management …”