BackgroundMaternal and Perinatal Death Surveillance and Review (MPDSR) can reduce mortality but its implementation is often suboptimal, especially in low- and middle-income countries (LMICs)... Show moreBackgroundMaternal and Perinatal Death Surveillance and Review (MPDSR) can reduce mortality but its implementation is often suboptimal, especially in low- and middle-income countries (LMICs).ObjectivesTo understand the determinants of behaviors influencing implementation of MPDSR in LMICs (through a systematic review of qualitative studies), in order to plan an intervention to improve its implementation.Search StrategyTerms for maternal or perinatal death reviews and qualitative studies.Selection CriteriaQualitative studies regarding implementation of MPDSR in LMICs.Data Collection and AnalysisWe coded the included studies using the Theoretical Domains Framework and COM-B model of behavior change (Capability, Opportunity, Motivation). We developed guiding principles for interventions to improve implementation of MPDSR.Main ResultsFifty-nine studies met our inclusion criteria. Capabilities required to conduct MPDSR (knowledge and technical/leadership skills) increase cumulatively from community to health facility and leadership levels. Physical and social opportunities depend on adequate data, human and financial resources, and a blame-free environment. All stakeholders were motivated to avoid negative consequences (blame, litigation, disciplinary action).ConclusionsImplementation of MPDSR could be improved by (1) introducing structural changes to reduce negative consequences, (2) strengthening data collection tools and information systems, (3) mobilizing adequate resources, and (4) building capabilities of all stakeholders.Implementation of MPDSR could be improved by introducing changes to reduce negative consequences, strengthening data collection tools, mobilizing resources, and building capabilities of all stakeholders. Show less
Tholandi, M.; Zethof, S.; Kim, Y.M.; Tura, A.K.; Ket, J.; Willcox, M.; ... ; Ilozumba, O. 2023
BackgroundIn the absence of robust vital registration systems, many low- and middle-income countries (LMICs) rely on national surveys or routine surveillance systems to estimate the maternal... Show moreBackgroundIn the absence of robust vital registration systems, many low- and middle-income countries (LMICs) rely on national surveys or routine surveillance systems to estimate the maternal mortality ratio (MMR). Although the importance of MMR estimates in ending preventable maternal deaths is acknowledged, there is limited research on how different approaches are used and adapted, and how these adaptations function.ObjectivesTo assess methods for estimating maternal mortality in LMICs and the rationale for these modifications.Search StrategyA literature search with the terms "maternal death", "surveys" and "low- and middle-income countries" was performed in Medline, Embase, Web of Science, Scopus, CINAHL, APA PsycINFO, ERIC, and IBSS from January 2013 to March 17, 2023.Selection CriteriaStudies were eligible if their main focus was to compare, adapt, or assess methods to estimate maternal mortality in LMICs.Data Collection and AnalysisTitles and abstracts were screened using Rayyan. Relevant articles were independently reviewed by two reviewers against inclusion criteria. Data were extracted on mortality measurement methods, their context, and results.Main ResultsNineteen studies were included, focusing on data completeness, subnational estimates, and community involvement. Routinely generated MMR estimates are more complete when multiple data sources are triangulated, including data from public and private health facilities, the community, and local authorities (e.g. vital registration, police reports). For subnational estimates, existing (e.g. the sisterhood method and reproductive-age mortality surveys [RAMOS]) and adapted methods (e.g. RAMOS 4 + 2 and Pictorial Sisterhood Method) provided reliable confidence intervals. Community engagement in data collection increased community awareness of maternal deaths, provided local ownership, and was expected to reduce implementation costs. However, most studies did not include a cost-effectiveness analysis.ConclusionHousehold surveys with community involvement and RAMOS can be used to increase data validity, improve local awareness of maternal mortality estimates, and reduce costs in LMICs.Scoping review evaluating 19 studies on estimating maternal mortality in low- and-middle-income countries, covering method completeness, provision of subnational estimates, and involvement of community members. Show less
Vries, P.L.M. de; Akker, T. van den; Bloemenkamp, K.W.M.; Grossetti, E.; Rigouzzo, A.; Saucedo, M.; ... ; Deneux-Tharaux, C. 2023
ObjectiveTo learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. MethodsIn this binational... Show moreObjectiveTo learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. MethodsIn this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. ResultsFor France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. ConclusionA binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level. Show less
Rebeiz, M.C.; El-Kak, F.; Akker, T. van den; Hamadeh, R.; McCall, S.J. 2023
ObjectiveTo identify the lessons learned from women who died during pregnancy or childbirth in Lebanon between 2018 and 2020. MethodThis is a case series and synthesis of maternal deaths between... Show moreObjectiveTo identify the lessons learned from women who died during pregnancy or childbirth in Lebanon between 2018 and 2020. MethodThis is a case series and synthesis of maternal deaths between 2018 and 2020 that were reported by healthcare facilities to the Ministry of Public Health in Lebanon. The notes recorded from the maternal mortality review reports were analyzed using the "Three Delays" model to identify preventable causes and lessons learned. ResultsA total of 49 women died before, during, or after childbirth, with hemorrhage being the most frequent cause (n = 16). The possible factors that would have prevented maternal deaths included a prompt recognition of clinical severity, availability of blood for transfusion and magnesium sulfate for eclampsia, adequate transfer to tertiary care hospitals comprising specialist care, and involvement of skilled medical staff in obstetric emergencies. ConclusionMany maternal deaths in Lebanon are preventable. Better risk assessment, use of an obstetric warning system, access to adequately skilled human resources and medications, and improved communication and transfer mechanisms between private and tertiary care hospitals may avoid future maternal deaths. Show less
Koskas, M.; Amant, F.; Mirza, M.R.; Creutzberg, C.L. 2021
Endometrial cancer is the most common gynecological malignancy in high- and middle-income countries. Although the overall prognosis is relatively good, high-grade endometrial cancers have a... Show moreEndometrial cancer is the most common gynecological malignancy in high- and middle-income countries. Although the overall prognosis is relatively good, high-grade endometrial cancers have a tendency to recur. Recurrence needs to be prevented since the prognosis for recurrent endometrial cancer is dismal. Treatment tailored to tumor biology is the optimal strategy to balance treatment efficacy against toxicity. Since The Cancer Genome Atlas defined four molecular subgroups of endometrial cancers, the molecular factors are increasingly used to define prognosis and treatment. Standard treatment consists of hysterectomy and bilateral salpingo-oophorectomy. Lymphadenectomy (and increasingly sentinel node biopsy) enables identification of lymph node-positive patients who need adjuvant treatment, including radiotherapy and chemotherapy. Adjuvant therapy is used for Stage I-II patients with high-risk factors and Stage III patients; chemotherapy is especially used in non-endometrioid cancers and those in the copy-number high molecular group characterized by TP53 mutation. In advanced disease, a combination of surgery to no residual disease and chemotherapy with or without radiotherapy results in the best outcome. Surgery for recurrent disease is only advocated in patients with a good performance status with a relatively long disease-free interval. Show less
Heitkamp, A.; Vollmer, L.; Akker, T. van den; Gebhardt, G.S.; Sandberg, E.M.; Roosmalen, J. van; ... ; Theron, G. 2021
Objective To assess the incidence of severe maternal outcome (SMO), comprising maternal mortality (MM) and maternal near miss (MNM), in Metro East health district, Western Cape Province, South... Show moreObjective To assess the incidence of severe maternal outcome (SMO), comprising maternal mortality (MM) and maternal near miss (MNM), in Metro East health district, Western Cape Province, South Africa between November 2014 and November 2015 and to identify associated determinants leading to SMO with the aim to improve maternity care.Methods Region-wide population-based case-control study. Women were included in the study, if they were maternal deaths or met MNM criteria, both as defined by WHO. Characteristics of women with SMO were compared with those of a sample of women without SMO, matched for age and parity, taken from midwifery-led obstetrical units from two residential areas in Metro East, using multivariate regression analysis.Results Incidence of SMO was 9.1 per 1000 live births, and incidence of MNM was 8.6 per 1000 live births. Main causes of SMO were obstetrical hemorrhage and hypertensive disorders. Factors associated with SMO were HIV (adjusted odds ratio [aOR] 24.8; 95% confidence interval [CI] 10.0-61.6), pre-eclampsia (aOR 17.5; 95% CI 7.9-38.7), birth by cesarean section (aOR 8.4; 95% CI 5.8-12.3), and chronic hypertension (aOR 2.4; 95% CI 1.1-5.1).Conclusion Evaluation of SMO incidence and associated determinants supports optimizing tailored guidelines in Metro-East health district to improve maternal health. Show less
Sheferaw, E.D.; Bakker, R.; Taddele, T.; Geta, A.; Kim, Y.M.; Akker, T. van den; Stekelenburg, J. 2020
Objective To assess the availability of an institutional-level respectful maternity care (RMC) index, its components, and associated factors.Methods A cross-sectional study design was applied to a... Show moreObjective To assess the availability of an institutional-level respectful maternity care (RMC) index, its components, and associated factors.Methods A cross-sectional study design was applied to a 2016 census of 3804 health facilities in Ethiopia. The availability of an institutional-level RMC index was computed as the availability of all nine items identified as important aspects of institutional-level RMC during childbirth. Logistic regression analysis was used to identify factors associated with availability of the index.Results Three components of the institutional-level RMC index were identified: "RMC policy," "RMC experience," and "facility for provision of RMC." Overall, 28% of facilities (hospitals, 29.9%; health centers, 27.8%) reported availability of the institutional-level RMC index. Facility location urbanization (urban region), percentage of maternal and newborn health workers trained in basic emergency obstetric and newborn care, and availability of maternity waiting homes in health facilities were positively associated with availability of the institutional-level RMC index.Conclusion Only one in three facilities reported availability of the institutional-level RMC index. The Ethiopian government should consider strengthening support mechanisms in different administrative regions (urban, pastoralist, and agrarian), implementing the provision training for health workers that incorporates RMC components, and increasing the availability of maternity waiting homes. Show less
Background Thermal coagulation is gaining popularity for treating cervical intraepithelial neoplasia (CIN) in screening programs in low- and middle-income countries (LMICs) due to unavailability of... Show moreBackground Thermal coagulation is gaining popularity for treating cervical intraepithelial neoplasia (CIN) in screening programs in low- and middle-income countries (LMICs) due to unavailability of cryotherapy. Objectives Assess the effectiveness of thermal coagulation for treatment of CIN lesions compared with cryotherapy, with a focus on LMICs. Search strategy Papers were identified from previous reviews and electronic literature search in February 2018 with publication date after 2010. Selection criteria Publications with original data evaluating cryotherapy or thermal coagulation with proportion of cure as outcome, assessed by colposcopy, biopsy, cytology, and/or visual inspection with acetic acid (VIA), and minimum 6 months follow-up. Data collection and analysis Pooled proportions of cure are presented stratified per treatment modality, type of lesion, and region. Main results Pooled cure proportions for cryotherapy and thermal coagulation, respectively, were 93.8% (95% CI, 88.5-97.7) and 91.4% (95% CI, 84.9-96.4) for CIN 1; 82.6% (95% CI, 77.4-87.3) and 91.6% (95% CI, 88.2-94.5) for CIN 2-3; and 92.8% (95% CI, 85.6-97.7) and 90.1% (95% CI, 87.0-92.8) for VIA-positive lesions. For thermal coagulation of CIN 2-3 lesions in LMICs 82.4% (95% CI, 75.4-88.6). Conclusions Both cryotherapy and thermal coagulation are effective treatment modalities for CIN lesions in LMICs. Show less
Heitkamp, A.; Seinstra, J.; Akker, T. van den; Vollmer, L.; Gebhardt, S.; Roosmalen, J. van; ... ; Theron, G. 2019
Objective To determine incidence, risk indicators, and outcomes of emergency peripartum hysterectomy (EPH) in Metro East, Cape Town, South Africa. Methods A population-based district-wide... Show moreObjective To determine incidence, risk indicators, and outcomes of emergency peripartum hysterectomy (EPH) in Metro East, Cape Town, South Africa. Methods A population-based district-wide prospective descriptive study of EPH in public hospitals from November 2014 to November 2015. Women were enrolled by using the WHO maternal near miss tool and followed until discharge. EPH was defined as hemorrhage or infection leading to hysterectomy during pregnancy or within 42 days of delivery. Results Fifty-nine women experienced EPH with an overall incidence of 14.3 per 10 000 women: 32 procedures were for postpartum hemorrhage, 27 for puerperal sepsis. Two women died: one from sepsis; one from hemorrhage. Overall, 51 (86%) women delivered by cesarean, and 23/51 (45%) by repeat cesarean. As compared with hemorrhage, EPH for sepsis involved older women (mean age, 31.5 vs 24.4 years) and those with higher gravidity (median, 3 vs 1), and was associated with longer hospital admission (median, 11.5 vs 4 days), with occurrence later postpartum (median, 8 vs 0 days), and more frequently with complications. Conclusions The incidence of EPH for sepsis was higher than previously reported. Repeat cesarean was strongly associated with EPH. Clinical characteristics of sepsis-related EPH compared unfavorably with those of hemorrhage-related EPH. Show less
Background: Thermal coagulation is gaining popularity for treating cervical intraepithelial neoplasia (CIN) in screening programs in low- and middle-income countries (LMICs) due to unavailability... Show moreBackground: Thermal coagulation is gaining popularity for treating cervical intraepithelial neoplasia (CIN) in screening programs in low- and middle-income countries (LMICs) due to unavailability of cryotherapy. Objectives: Assess the effectiveness of thermal coagulation for treatment of CIN lesions compared with cryotherapy, with a focus on LMICs. Search strategy: Papers were identified from previous reviews and electronic literature search in February 2018 with publication date after 2010. Selection criteria: Publications with original data evaluating cryotherapy or thermal coagulation with proportion of cure as outcome, assessed by colposcopy, biopsy, cytology, and/or visual inspection with acetic acid (VIA), and minimum 6 months follow-up. Data collection and analysis: Pooled proportions of cure are presented stratified per treatment modality, type of lesion, and region. Main results: Pooled cure proportions for cryotherapy and thermal coagulation , respectively, were 93.8% (95% CI, 88.5–97.7) and 91.4% (95% CI, 84.9–96.4) for CIN 1; 82.6% (95% CI, 77.4–87.3) and 91.6% (95% CI, 88.2–94.5) for CIN 2–3; and 92.8% (95% CI, 85.6–97.7) and 90.1% (95% CI, 87.0–92.8) for VIA-positive lesions. For thermal coagulation of CIN 2–3 lesions in LMICs 82.4% (95% CI, 75.4–88.6). Conclusions: Both cryotherapy and thermal coagulation are effective treatment modalities for CIN lesions in LMICs. Show less
Amant, F.; Mirza, M.R.; Koskas, M.; Creutzberg, C.L. 2018
Endometrial cancer is the most common gynecological malignancy in high-income countries. Although the overall prognosis is relatively good, high-grade endometrial cancers have a tendency to recur.... Show moreEndometrial cancer is the most common gynecological malignancy in high-income countries. Although the overall prognosis is relatively good, high-grade endometrial cancers have a tendency to recur. Recurrence needs to be prevented since the prognosis for recurrent endometrial cancer is dismal. Treatment tailored to tumor biology is the optimal strategy to balance treatment efficacy against toxicity. Standard treatment consists of hysterectomy and bilateral salpingo-oophorectomy. Lymphadenectomy (with ongoing studies of sentinel node biopsy) enables identification of lymph node positive patients who need adjuvant treatment, including radiotherapy and chemotherapy. Adjuvant radiotherapy is used for Stage I-II patients with high-risk factors and Stage III lymph node negative patients. In advanced disease, a combination of surgery to no residual disease and chemotherapy results in the best outcome. Surgery for recurrent disease is only advocated in patients with a good performance status with a relatively long disease-free interval. Show less
Nolens, B.; Namiiro, F.; Lule, J.; Akker, T. van den; Roosmalen, J. van; Byamugisha, J. 2018
Objective: To assess the length and angle of mediolateral episiotomies performed by midwives and resident gynecologists at 3 teaching hospitals in the Netherlands, and determine the incidence of... Show moreObjective: To assess the length and angle of mediolateral episiotomies performed by midwives and resident gynecologists at 3 teaching hospitals in the Netherlands, and determine the incidence of obstetric anal sphincter injury. Methods: In this prospective audit conducted between February and September 2008, all women delivered at the 3 hospitals were examined in the labor room for perineal injury. When an injury was assessed as being grade 2 or higher, it was re-evaluated. The incidence of anal sphincter injury was then compared with that reported in the preceding year. Results: Of 1979 women delivered, 420 (21.2%) were given an episiotomy and 58 (2.9%) sustained anal sphincter injury. The episiotomies formed a mean angle of 40 degrees with the perineal midline. There was no difference in length or angle between the episiotomies performed by resident gynecologists and those performed by midwives, and the angle of most episiotomies was sufficiently wide. Compared with the preceding year, the rate of anal sphincter injury was significantly higher. Conclusion: The quality of episiotomies did not differ when performed by midwives or resident gynecologists. To improve the recognition and classification of obstetric anal sphincter injuries, audits based on an internationally accredited classification could easily become a part of routine hospital practice. (C) 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. Show less
