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  • 1.
    Kamala, B.
    et al.
    Univ Stavanger, Dept Hlth Sci, Stavanger, Norway;Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania.
    Mgaya, Andrew
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania.
    Ngarina, M.
    Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania.
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania.
    Predictors of low birthweight and 24-hour survival rate at Muhimbili National Hospital in Dar es Salaam: A 5-year retrospective analysis of obstetric records2017In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 124, p. 20-20Article in journal (Other academic)
  • 2.
    Kamala, Benjamin Anathory
    et al.
    Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania; Univ Stavanger, Dept Hlth Sci, Stavanger, Norway.
    Mgaya, Andrew Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania.
    Ngarina, Matilda Michael
    Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania.
    Kidanto, Hussein Leiso
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania.
    Predictors of low birth weight and 24-hour perinatal outcomes at Muhimbili National Hospital in Dar es Salaam, Tanzania: a five-year retrospective analysis of obstetric records2018In: Pan African Medical Journal, E-ISSN 1937-8688, Vol. 29, article id 220Article in journal (Refereed)
    Abstract [en]

    Introduction: the global prevalence of low birth weight (LBW) is 16%, representing more than 20 million infants worldwide, of which 96% are born in low-income countries. This study aimed to determine the prevalence, predictors and perinatal outcomes of LBW newborns.

    Methods: we conducted a retrospective analysis of data obtained from the hospital's obstetric and neonatal database. Descriptive statistics and multivariate logistic regression were performed with 95% confidence intervals (CI).

    Results: the prevalence of LBW was 21% (n = 8,011) and two-thirds of these were delivered at term. Seven percent of newborns were stillbirths and 2% died within 24hrs after birth. Logistic regression revealed that primigravida and grand multiparity were associated with LBW (OR: 1.25, 95%CI: 1.15-1.37; and OR: 1.21, 95%CI: 1.01-1.25, respectively). Having <4 antenatal care (ANC) visits was associated with increased odds of LBW (OR: 1.74, 95%CI: 1.59-1.87). Regression models revealed an independent association between LBW and increased odds of stillbirths (OR = 7.20, 95%CI 6.71-7.90), low Apgar score (OR = 3.42, 95%CI: 3.12-3.76) and early neonatal deaths (OR = 1.82, 95%CI: 1.51-2.19).

    Conclusion: the prevalence of LBW was high and was associated with extreme maternal age groups, grand multiparity, low maternal education, low number of ANC visits and obstetrics risks factors and complications. Both LBW and prematurity were independently associated with poor perinatal outcome. Future interventions should focus on improving the quality of ANC and integrating peripartum emergency obstetric and neonatal care.

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  • 3.
    Litorp, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mgaya, Andrew
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Johnsdotter, Sara
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    "What about the mother?": Women's and caregivers' perspectives on caesarean birth in a low-resource setting with rising caesarean section rates2015In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 31, no 7, p. 713-720Article in journal (Refereed)
    Abstract [en]

    Objective: in light of the rising caesarean section rates in many developing countries, we sought to explore women's and caregivers' experiences, perceptions, attitudes, and beliefs in relation to caesarean section. Design: qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis. Setting: a public university hospital in Dar es Salaam, Tanzania. Participants: we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each Women had undergone a caesarean section within two months preceding the interview and were interviewed in their homes. Caregivers were consultants, specialists, residents, and midwives. Findings: both women and caregivers preferred vaginal birth, but caregivers also had a favourable attitude towards caesarean section. While caregivers emphasised their efforts to counsel women on caesarean section, women had often reacted with fear and shock to the caesarean section decision and perceived that there was a lack of indications. Although caesarean section was perceived as involving higher maternal risks than vaginal birth, both women and caregivers justified these risks by the need to 'secure' a healthy baby. Religious beliefs and community members seemed to influence women's caesarean section attitudes, which often made caregivers frustrated as it diminished their role as decision makers Undergoing caesarean section had negative socio-economic consequences for women and their families; however, caregivers seldom took these factors into account when making decisions. Key conclusions and implications for practice: we raise a concern that women and caregivers might overlook maternal risks with caesarean section for the benefit of the baby, a shift in focus that can have serious consequences on women's health in low-resource settings. Caregivers need to reflect on how they counsel women on caesarean section, as many women perceived a lack of indication for their operations. Supportive attendance by a relative during birth and more comprehensive antenatal care counselling about caesarean section indications and complications might enhance women's autonomy and birth preparedness.

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  • 4.
    Litorp, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mgaya, Andrew
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mbekenga, Columba K.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Johnsdotter, Sara
    Malmo Univ, Fac Hlth & Soc, S-20506 Malmo, Sweden.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting2015In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 143, p. 232-240Article in journal (Refereed)
    Abstract [en]

    In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5-6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings in the discussion of how transparency and auditing can induce behavioral change and have unintended effects. Caregivers had divergent opinions on whether the hospital's CS rate was a problem or not, but most thought that there was an overuse of CS. All caregivers rationalized the high CS rate by referring to circumstances outside their control. In private practice, some stated they were affected by the economic compensation for CS, while others argued that unnecessary CSs were due to maternal demand. Residents often missed support from their senior colleagues when making decisions, and felt that midwives pushed them to perform CSs. Many caregivers stated that their fear of blame from colleagues and management in case of poor outcomes made them advocate for, or perform, CSs on doubtful indications. In order to lower CS rates, caregivers must acknowledge their roles as decision-makers, and strive to minimize unnecessary CSs. Although auditing and transparency are important to improve patient safety, they must be used with sensitivity regarding any unintended or counterproductive effects they might have.

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  • 5.
    Makokha-Sandell, Henrik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Mgaya, Andrew
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration. Muhimbili Univ Hlth & Allied Sci, POB 65001, Dar Es Salaam, Tanzania..
    Belachew, Johanna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Global Health Research on Implementation and Sustainability.
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Aga Khan Univ, Med Coll, POB 38129, Dar Es Salaam, Tanzania.;Muhimbili Natl Hosp, Dar Es Salaam, Tanzania..
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Low use of vacuum extraction: Health care Professionals' Perspective in a University Hospital, Dar es Salaam2020In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 25, article id 100533Article in journal (Refereed)
    Abstract [en]

    Background: Use of vacuum extraction (VE) has been declining in low and middle income countries. At the highest referral hospital Tanzania, 54% of deliveries are performed by caesarean section (CS) and only 0.8% by VE. Use of VE has the potential to reduce CS rates and improve maternal and neonatal outcomes but causes for its low use is not fully explored.

    Method: During November and December of 2017 participatory observations, semi-structured in-depth interviews (n = 29) and focus group discussions (n = 2) were held with midwives, residents and specialists working at the highest referral hospital in Tanzania. Thematic analysis was used to identify rationales for low VE use.

    Findings: Unstructured and inconsistent clinical teaching structure, interdependent on a fear and blame culture, as well as financial incentives and a lack of structured, adhered to and updated guidelines were identified as rationales for CS instead of VE use. Although all informants showed positivity towards clinical teaching of VE, a subpar communication between clinics and academia was stated as resulting in absent clinical teachers and unaccountable students.

    Conclusion: This study draws connections between the low use of VE and the inconsistent and unstructured clinical training of VE expressed through the health care providers' points of view. However, clinical teaching in VE was highly welcomed by the informers which may serve as a good starting point for future interventions.

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  • 6.
    Mapunda, Bosco
    et al.
    Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania..
    August, Furaha
    Muhimbili Univ Hlth & Allied Sci, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania..
    Mwakawanga, Dorkas
    Muhimbili Univ Hlth & Allied Sci, Dept Nursing & Midwifery, Dar Es Salaam, Tanzania..
    Mhando, Isaya
    St Joseph Coll Hlth & Allied Sci, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania..
    Mgaya, Andrew
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Reproductive Health and Migration. Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania..
    Prevalence and barriers to male involvement in antenatal care in Dar es Salaam, Tanzania: A facility-based mixed-methods study2022In: PLOS ONE, E-ISSN 1932-6203, Vol. 17, no 8, article id e0273316Article in journal (Refereed)
    Abstract [en]

    Background: Men have traditionally not been fully involved in reproductive health care of their partners, and yet, they play a crucial role in family decision-making and therefore crucial key players in preventing poor pregnancy outcomes. This study aimed to assess prevalence and determinants of male participation in maternal health care and explore male partners' perspective of their involvement in antenatal care at an urban tertiary referral facility.

    Methods: A mixed-methods study was conducted from October 2018 to January 2019 at Muhimbili National Hospital. A cross-sectional survey of 428 nursing mothers and two focus group discussions of male partners (n = 7 and n = 11) of women attending antenatal clinic and nursing mothers in the post-natal ward were performed. Using SPSS Ver. 23 (IBM, Chicago, IL), frequency distribution tables summarized demographic data and categories of male partners' involvement in antenatal care. Focus group discussions included male partners of age from 24 to 55 years at their first to fifth experience of pregnancy and childbirth. Interviews were audio-recorded, and then transcribed and coded. Thematic analysis was applied.

    Results: The prevalence of male involvement in antenatal care was 69%. More than two-thirds of nursing mothers received physical, psychological and financial support from partners (76%) and attended four or more antenatal visits (85%). Five themes of male perspective of their involvement in antenatal care were generated, including: a) cultural norms and gender roles, b) ignorance of reproductive health service, c) factors outside their control, d) couple interaction and conflicts, and e) institutional obstacles.

    Conclusion: The prevalence of male partners' involvement in antenatal care was relatively high. Men's involvement in antenatal care depended on access to antenatal care education, standards of structure and process of antenatal service and how well their role was defined in the maternal health care system. Interactions and practice in society, employment sector and government health system should complement strategies to promote men's involvement in maternal health.

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  • 7.
    Mgaya, Andrew H.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration. Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania.
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration. Minist Hlth Community Dev Gender Elderly & Childr, Reprod & Child Hlth, Dar Es Salaam, Tanzania.
    Nystrom, Lennarth
    Umea Univ, Dept Publ Hlth & Clin Med, Epidemiol & Global Hlth Unit, Umea, Sweden.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Use of a criteria-based audit to optimize uptake of cesarean delivery in a low-resource setting2019In: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 144, no 2, p. 199-209Article in journal (Refereed)
    Abstract [en]

    Objective: To evaluate the impact of a criteria-based audit (CBA) of obstructed labor and fetal distress on cesarean delivery and perinatal outcomes.

    Methods: A cross-sectional study was performed at a tertiary referral hospital in Tanzania. Data were collected before and after CBA (January 2013-November 2013 and July 2015-June 2016). Outcomes of fetal distress (baseline CBA, n=248; re-audit, n=251) and obstructed labor (baseline CBA, n=260; re-audit n=250) were assessed using a checklist. Additionally, 27 960 parturients were assessed using the Robson classification.

    Results: Perinatal morbidity and mortality decreased from 42 of 260 (16.2%) to 22 of 250 (8.8%) among patients with obstructed labor after CBA (P=0.012). Cesarean delivery rate decreased for referred term multiparas with induced labor or prelabor cesarean delivery (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.09-0.82). Cesarean delivery rate for preterm pregnancies increased among both referred (OR 1.28, 95% CI 1.02-1.63) and non-referred (OR 2.78, 95% CI 1.98-3.90) groups. Neonatal distress rate decreased for referred term multiparas (OR 0.72, 95% CI 0.56-0.92), referred preterm pregnancies (OR 0.32, 95% CI 0.25-0.39), and non-referred preterm pregnancies (OR 0.26, 95% CI 0.18-0.36).

    Conclusion: Use of CBA reduced poor perinatal outcomes of obstructed labor and increased uptake of cesarean delivery.

  • 8.
    Mgaya, Andrew Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Improving the quality of caesarean section in a low-resource setting: An intervention by criteria-based audit at a tertiary hospital, Dar es Salaam, Tanzania2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    A sharp increase in caesarean section (CS) rates at the Muhimbili National Referral Hospital (MNH) – a tertiary referral hospital in Tanzania – by 50% in 2000–2011, was associated with concomitant increase in maternal complications and deaths and inconsistent improvement in newborn outcomes. The aims of this thesis were to explore care providers’ in-depth perspective of the reasons for these high rates of CS, and to evaluate and improve standards of care for the most common indica-tions of CS, obstructed labour and fetal distress, which are also major causes of adverse maternal and neonatal outcomes.

    This thesis reports an investigation performed at MNH, Tanzania. For Paper I, qualitative methods were employed and demonstrated how care providers dismissed their responsibility for the rising CS rate; and, instead, projected the causes onto factors beyond their control. Additionally, dysfunctinal teamwork, transparency, and previous poorly conducted clinical audits led to fear of blame among care providers in cases of poor outcome that subsequently encougared defensive practise by assigning unnecessary CS. Papers II and III evaluated stand-ards of care using a criteria-based audit (CBA) of obstructed labour and fetal dis-tress. After implementing audit-feedback recommendations, the standards of diag-nosis of fetal distress improved by 16% and obstructed labour by 7%. Similarly, the standards of management preceding CS improved tenfold for fetal distress and doubled for obstructed labour. The impact of the CBA process was evaluated by comparing the maternal and perinatal outcomes categorized into Robson groups (Paper IV) of all deliveries occurring before and after the audit process (n=27,960). After the CBA process, there was a 50% risk reduction of severe perinatal morbidi-ty/mortality for patients with obstructed labour. The overall CS rates increased by 10%, and this was attributed to an increase in the CS rate among breech, term preg-nancies (Robson group 6), and preterm pregnancies (Robson group 10) that specifi-cally had reduced risk of poor perinatal outcome. The overall neonatal distress rates were also reduced by 20%, and this was attributed to a decrease in the neonatal distress rate among low-risk, term pregnancies (Robson group 3). Importantly, the increased rates of poor perinatal outcomes were associated with referred patients that had higher risk of neonatal distress and PMR than non–referred patients, after CBA process. 

    In conclusion, the studies managed to educate the care providers to take on their roles as decision-makers and medical experts to minimize unnecessary CS, using the available resources. Care providers’ commitment to achieve the best practice should be sustained and effort for stepwise upgrading quality of obstetric care should be supported by the hospital management from the primary to tertiary referral level.

    List of papers
    1. Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting
    Open this publication in new window or tab >>Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting
    Show others...
    2015 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 143, p. 232-240Article in journal (Refereed) Published
    Abstract [en]

    In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5-6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings in the discussion of how transparency and auditing can induce behavioral change and have unintended effects. Caregivers had divergent opinions on whether the hospital's CS rate was a problem or not, but most thought that there was an overuse of CS. All caregivers rationalized the high CS rate by referring to circumstances outside their control. In private practice, some stated they were affected by the economic compensation for CS, while others argued that unnecessary CSs were due to maternal demand. Residents often missed support from their senior colleagues when making decisions, and felt that midwives pushed them to perform CSs. Many caregivers stated that their fear of blame from colleagues and management in case of poor outcomes made them advocate for, or perform, CSs on doubtful indications. In order to lower CS rates, caregivers must acknowledge their roles as decision-makers, and strive to minimize unnecessary CSs. Although auditing and transparency are important to improve patient safety, they must be used with sensitivity regarding any unintended or counterproductive effects they might have.

    Keywords
    Tanzania; Caesarean section; Low-resource setting; Attitudes; Caregivers; Transparency
    National Category
    Obstetrics, Gynecology and Reproductive Medicine
    Identifiers
    urn:nbn:se:uu:diva-238477 (URN)10.1016/j.socscimed.2015.09.003 (DOI)000364245600027 ()26364010 (PubMedID)
    Funder
    Swedish Research Council
    Available from: 2014-12-15 Created: 2014-12-12 Last updated: 2017-12-05Bibliographically approved
    2. Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania
    Open this publication in new window or tab >>Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania
    Show others...
    2016 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 343Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: In Tanzania, substandard intrapartum management of foetal distress contributes to a third of perinatal deaths, and the majority are term deliveries. We conducted a criteria-based audit with feedback to determine whether standards of diagnosis and management of foetal distress would be improved in a low-resource setting.

    METHODS: During 2013-2015, a criteria-based audit was performed at the national referral hospital in Dar es Salaam. Case files of deliveries with a diagnosis of foetal distress were identified and audited. Two registered nurses under supervision of a nurse midwife, a specialist obstetrician and a consultant obstetrician, reviewed the case files. Criteria for standard diagnosis and management of foetal distress were developed based on international and national guidelines, and literature reviews, and then, stepwise applied, in an audit cycle. During the baseline audit, substandard care was identified, and recommendations for improvement of care were proposed and implemented. The effect of the implementations was assessed by the differences in percentage of standard diagnosis and management between the baseline and re-audit, using Chi-square test or Fisher's exact test, when appropriate.

    RESULTS: In the baseline audit and re-audit, 248 and 251 deliveries with a diagnosis of foetal distress were identified and audited, respectively. The standard of diagnosis increased significantly from 52 to 68 % (p < 0.001). Standards of management improved tenfold from 0.8 to 8.8 % (p < 0.001). Improved foetal heartbeat monitoring using a Fetal Doppler was the major improvement in diagnoses, while change of position of the mother and reduced time interval from decision to perform caesarean section to delivery were the major improvements in management (all p < 0.001). Percentage of cases with substandard diagnosis and management was significantly reduced in both referred public and non-referred private patients (all p ≤ 0.01) but not in non-referred public and referred private patients.

    CONCLUSION: The criteria-based audit was able to detect substandard diagnosis and management of foetal distress and improved care using feedback and available resources.

    National Category
    Clinical Medicine
    Identifiers
    urn:nbn:se:uu:diva-307491 (URN)10.1186/s12884-016-1137-z (DOI)000387607600003 ()27825311 (PubMedID)
    Available from: 2016-11-16 Created: 2016-11-16 Last updated: 2017-11-29Bibliographically approved
    3. Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania
    Open this publication in new window or tab >>Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania
    2016 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 11, no 11, article id e0166619Article in journal (Refereed) Published
    Abstract [en]

    Objective In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting. Methods A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit. Results Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01). Conclusion A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.

    National Category
    Obstetrics, Gynecology and Reproductive Medicine
    Identifiers
    urn:nbn:se:uu:diva-312977 (URN)10.1371/journal.pone.0166619 (DOI)000389472400035 ()27893765 (PubMedID)
    Note

    Contributed equally to this work with: Andrew H. Mgaya, Hussein L. Kidanto, Lennarth Nystrom, Birgitta Essén

    Available from: 2017-02-10 Created: 2017-02-10 Last updated: 2021-06-14Bibliographically approved
    4. Optimizing the use of cesarean section in a low resource setting: Criteria-Based Audit at a tertiary referral hospital in Tanzania.
    Open this publication in new window or tab >>Optimizing the use of cesarean section in a low resource setting: Criteria-Based Audit at a tertiary referral hospital in Tanzania.
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    Abstract [en]

    Introduction. Substandard intrapartum care contributes to maternal and perinatal morbidity in low-resource settings. The aim was to estimate the impact of a criteria-based audit (CBA) of obstructed labour (OL) and fetal distress (FD), at a tertiary referral hospital in Tanzania. Material and Methods. The CBA included a baseline audit (December 2013-June 2014) followed by implementation of audit recommendations (March-June 2015). A before-and-after survey of maternal and perinatal outcomes included 499 patients with FD (baseline audit n=248; re-audit n=251) and 510 with OL (baseline n=260; re-audit n=250). Patients with OL and FD were grouped as OL (baseline audit n=82; re-audit n=76). The maternal and perinatal outcomes of 27,960 deliveries were analysed in 10 Robson groups, which are mutually exclusive and reproducible, unlike CS indications, FD and OL. Bivariate and multivariate logistic regression estimated the likelihood of CS, neonatal distress rate and perinatal mortality rate (PMR) after the CBA. Results. Perinatal morbidity and mortality decreased (16% vs. 8.8%; p=0.01) for the OL group. The likelihood of CS increased for nulliparous, singleton, breech, term pregnancies (Robson group 6) (adjusted odds ratio (aOR) 5.2, 95% confidence interval (CI); 1.4-19) and singleton, preterm pregnancies (Robson group 10) (aOR 1.6, 95%CI; 1.4-2.0). Similarly, the overall likelihood of CS increased (aOR 1.1, 95%CI; 1.1-1.2). The neonatal distress rate decreased for multiparas (excluding previous CS), singleton, term pregnancies (Robson group 3) (aOR 0.76, 0.62-0.95) and singleton, preterm pregnancies (aOR 0.30, 95%CI; 0.25-0.36). The singleton, preterm pregnancies also had a decreased PMR (aOR 0.58, 95%CI; 0.46-0.78). The overall neonatal distress and PMR were comparable before and after the CBA process. Conclusion: With the use of Robson classification we could demonstrate that CBA is a feasible and reliable tool that improved perinatal outcome of OL and optimized benefits of CS in relatively high- and low-risk pregnancies.

    Keywords
    Cesarean section, criteria-based audit, fetal distress, obstructed labour, low resource setting, Robson classification
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-319055 (URN)
    Available from: 2017-03-31 Created: 2017-03-31 Last updated: 2017-03-31
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  • 9.
    Mgaya, Andrew
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynecol, POB 65000, Dar Es Salaam, Tanzania..
    Hinju, Januarius
    Benjamin Mkapa Referral Hosp, Dept Obstet & Gynecol, Dodoma, Tanzania..
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynecol, POB 65000, Dar Es Salaam, Tanzania.;Muhimbili Univ Hlth & Allied Sci, Dept Obstet & Gynecol, Dar Es Salaam, Tanzania..
    Is time of birth a predictor of adverse perinatal outcome?: A hospital-based cross-sectional study in a low-resource setting, Tanzania2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, article id 184Article in journal (Refereed)
    Abstract [en]

    Background: Inconsistent evidence of a higher risk of adverse perinatal outcomes during off-hours compared to office hours necessitated a search for clear evidence of an association between time of birth and adverse perinatal outcomes. Methods: A cross-sectional study conducted at a tertiary referral hospital compared perinatal outcomes across three working shifts over 24 h. A checklist and a questionnaire were used to record parturients' socio-demographic and obstetric characteristics, mode of delivery and perinatal outcomes, including 5th minute Apgar score, and early neonatal mortality. Risks of adverse outcomes included maternal age, parity, referral status and mode of delivery, and were assessed for their association with time of delivery and prevalence of fresh stillbirth as a proxy for poor perinatal outcome at a significance level of p = 0.05. Results: Off-hour deliveries were nearly twice as likely to occur during the night shift (odds ratio (OR), 1.62; 95% confidence interval (CI), 1.50-1.72), but were unlikely during the evening shift (OR, 0.58; 95% CI, 0.45-0.71) (all p < 0.001). Neonatal distress (O.R, 1.48, 95% CI; 1.07-2.04, p = 0.02), early neonatal deaths (OR, 1.70; 95% CI, 1.07-2.72, p = 0.03) and fresh stillbirths (OR, 1.95; 95% CI, 1.31-2.90, p = 0.001) were more significantly associated with deliveries occurring during night shifts compared to evening and morning shifts. However, fresh stillbirths occurring during the night shift were independently associated with antenatal admission from clinics or wards, referral from another hospital, and abnormal breech delivery (OR 1.9; 95% CI, 1.3-2.9, p = 0.001, for fresh stillbirths; OR, 5.0; 95% CI 1.7-8.3, p < 0.001, for antenatal admission; OR, 95% CI, 1.1-2.9, p < 0.001, for referral form another hospital; and OR 1.6; 95% CI 1.02-2.6, p = 0.004, for abnormal breech deliveries). Conclusion: Off-hours deliveries, particularly during the night shift, were significantly associated with higher proportions of adverse perinatal outcomes, including low Apgar score, early neonatal death and fresh stillbirth, compared to morning and evening shifts. Labour room admissions from antenatal wards, referrals from another hospital and abnormal breech delivery were independent risk factors for poor perinatal outcome, particularly fresh stillbirths.

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  • 10.
    Mgaya, Andrew
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania..
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Minist Hlth Community Dev Gender Elderly & Childr, Reprod & Child Hlth Sect, Dar Es Salaam, Tanzania..
    Nystrom, Lennarth
    Umea Univ, Dept Publ Hlth & Clin Med Epidemiol & Global Hlth, Umea, Sweden..
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania2016In: PLOS ONE, E-ISSN 1932-6203, Vol. 11, no 11, article id e0166619Article in journal (Refereed)
    Abstract [en]

    Objective In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting. Methods A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit. Results Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01). Conclusion A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.

  • 11.
    Misaeli, C. G.
    et al.
    Muhimbili University of Health and Allied Science, Department of Obstetrics and Gynaecology.
    Kamala, B. A.
    Muhimbili National Hospital, Department of Obstetrics and Gynaecology; University of Stavanger, Department of Health Science.
    Mgaya, Andrew
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili National Hospital, Department of Obstetrics and Gynaecology.
    Kidanto, Hussein Leiso
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili National Hospital, Department of Obstetrics and Gynaecology.
    Factors associated with women's intention to request caesarean delivery in Dar es Salaam, Tanzania2017In: Sajog-South African Journal Of Obstetrics And Gynaecology, ISSN 0038-2329, Vol. 23, no 2, p. 56-62Article in journal (Refereed)
    Abstract [en]

    Background. In the past decade, the rate of caesarean section (CS) has increased dramatically in many parts of the world. At Muhimbili National Hospital (MNH) there has been a dramatic rise in the caesarean section rate over the past decade.

    Objective. To determine the incidence of maternal request for CS and factors associated with intention to request caesarean section at the MNH antenatal clinic.

    Methods. We conducted a cross-sectional study from August to October 2014. A structured questionnaire gathered participants' background and obstetric information, perceptions and opinions regarding a request for caesarean section, and the respective reasons for the request. Confidence intervals were calculated and a p-value <0.05 was considered significant.

    Results. The incidence of CS on maternal request was about 6%. The intention to request for CS in the index pregnancy was 8%. Higher-level education and formal-sector employment had higher odds for requesting CS (p=0.01 and p=0.05, respectively). Half of the participants agreed that maternal request for CS should be allowed; more private patients agreed that it could affect the doctor-patient relationship (p=0.02); more private patients agreed that request for CS was due to fear of losing a child (p=0.03). Previous history of CS was an independent predictor of maternal request for caesarean section (OR 1.7; 95% CI 1.7-15.4) and (OR 5.8; 95% CI 1.6-20.1), respectively.

    Conclusion. Maternal requests for CS exist at the national referral hospital in Tanzania. This was associated with factors other than women's preferences, including perceived fear of child loss and events associated with previous CS.

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  • 12.
    Misaeli, C.
    et al.
    Muhimbili Univ Hlth & Allied Sci, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania.
    Mgaya, Andrew
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania.
    Kamala, B.
    Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania;Univ Stavanger, Dept Hlth Sci, Stavanger, Norway.
    Kidanto, H.
    Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania;Minist Hlth Community Dev Gender Elders & Childre, Reprod Maternal & Child Hlth, Dar Es Salaam, Tanzania.
    Factors associated with women's intention of requesting caesarean delivery in Dar es Salaam, Tanzania2017In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 124, p. 126-126Article in journal (Other academic)
1 - 12 of 12
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