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Background: Tranexamic acid (TXA) is increasingly used in the management of haemorrhage during and after delivery and haemorrhage caused by other medical conditions due to its efficacy and safety. However, increasing report of fatal complications from inadvertent intrathecal TXA injection remains a cause of concern. The aim of this case report is to demonstrate clinical presentation and predictors of accidental intrathecal injection of TXA within the structure and processes of care in a health facility.

Case Description: A 37-year-old woman, multiparous woman presented with a diagnosis of obstructed labour and, therefore, was scheduled for emergency caesarean section. She was assigned the American Society of Anesthesiology II physical status. Spinal anaesthesia was performed at a sitting position through L4-L5 interspace using a 25-G spinal needle gauge. The anaesthetist injected 3 mL of an aesthetic agent that was prepared earlier as hyperbaric bupivacaine 0.5%. About 2 min after receiving the injection, the patient reported gluteal discomfort and itching and severe back pain. She subsequently developed progressive altered mentation followed by generalized tonic–clonic seizures. General anaesthesia was conducted with propofol (100 mg), pethidine (50 mg) and suxamethonium (100 mg). Episodes of tonic–clonic seizures continued despite treatment with multiple doses of diazepam (10 mg), propofol (100 mg) and phenytoin infusion (1 gm). Postoperatively, the patient was transferred to the intensive care unit with persistent tachycardia (125–138 beats per minute), hypertension (157/105–175/118 mmHg) and oxygen saturation of 90%–95%. She died due to cardiac arrest after 21 h of stay.

Conclusion: Medication error such as accidental intrathecal injection of TXA continues to jeopardise the safety of surgery under spinal anaesthesia.

Introduction:  burst abdomen is a preventable complication of caesarean section that carries an increased risk of maternal death, especially in developing countries including Tanzania. The study aimed to identify the risk factors and high-risk patients for burst abdomen at Muhimbili National Hospital in Tanzania.

Methods:  a case-control study was performed at Muhimbili National Hospital in Dar es Salaam from 2nd April to 27th December 2019. Characteristics of interest of one case of burst abdomen were compared to three randomly selected controls that consisted of caesarean deliveries either 24 hours before or after the time of delivery of cases. The chi-square test, Fischer´s exact test, and multivariate analysis were used. The level of significance was p < 0.05.

Results:  a total of 524 women that met the inclusion criteria, comprising 131 cases and 393 controls, delivered by caesarean section in the most recent pregnancy at Muhimbili National Hospital. Cases were independently associated with perioperative illness, including cough (OR 3.8, 95%CI 1.9-7.6), chorioamnionitis (OR 4.5, 95% CI 1.3-14.7), and surgical site infection (OR 3.2, 95% CI 1.7-6.4), and a vertical midline incision wound (OR 1.9, 95% CI 1.2-3.1) compared to control group. Most cases (70%) had intact sutures and loose surgical knots.

Conclusion:  burst abdomen remains a cause of unnecessary severe maternal morbidity and is independently associated with perioperative illnesses such as cough, chorioamnionitis surgical site infection, and a vertical midline abdominal incision. Thus, there is a need for modifying abdominal fascia closure techniques for patients at risk.

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.

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.

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.

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.

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.

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.

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.