Assessment of quality of obstetric care in Zimbabwe using the standard primipara

BMC Pregnancy and Childbirth, Volume 18, No. 1, Year 2018

Interpretation

Background: To improve maternity services in any country, there is need to monitor the quality of obstetric care. There is usually disparity of obstetric care and outcomes in most countries among women giving birth in different obstetric units. However, comparing the quality of obstetric care is difficult because of heterogeneous population characteristics and the difference in prevalence of complications. The concept of the standard primipara was introduced as a tool to control for these various confounding factors. This concept was used to compare the quality of obstetric care among districts in different geographical locations in Zimbabwe. Methods: This was a substudy of the Zimbabwe Maternal and Perinatal Mortality Study. In the main study, cluster sampling was done with the provinces as clusters and 11 districts were randomly selected with one from each of the nine provinces and two from the largest province. This database was used to identify the standard primipara defined as; a woman in her first pregnancy without any known complications who has spontaneous onset of labour at term. Obstetric process and outcome indicators of the standard primipara were then used to compare the quality of care between rural and urban, across rural and across urban districts of Zimbabwe. Results: A total of 45,240 births were recruited in the main study and 10,947 women met the definition of standard primipara. The maternal mortality ratio (MMR) and the perinatal mortality rate (PNMR) for the standard primiparae were 92/100000 live births and 15.4/1000 total births respectively. Compared to urban districts, the PNMR was higher in the rural districts (11/1000 total births vs 19/ 1000 total births, p < 0.001). In the urban to urban and rural to rural districts comparison, there were significant differences in most of the process indicators, but not in the PNMR. Conclusions: The study has shown that the standard primipara can be used as a tool to measure and compare the quality of obstetric care in districts in different geographical areas. There is need to explore further how the quality of obstetric care can be improved in rural districts of Zimbabwe. Zimbabwe is divided into 10 administrative Provinces, which are divided into 59 Districts. Harare, the biggest Province has urban districts only unlike all the other Provinces which are comprised of urban and rural districts. The Zimbabwe Maternal and Perinatal Mortality Study (ZMPMS) was a population-based descriptive and cross-sectional study of deaths of women in pregnancy and perinatal deaths in Zimbabwe. The study was done to estimate the maternal mortality ratio (MMR) and the perinatal mortality rate (PNMR) in Zimbabwe [8]. Data were collected from the 1st of May 2007 to the 30th April 2008. Cluster sampling was done with the 10 provinces as clusters and 11 districts were randomly selected with one from each of the 9 provinces and 2 from Harare which is the biggest province in Zimbabwe. In these 11 districts, pregnancy outcomes were collected prospectively on all women delivering after 22 weeks gestation for 11 months [8]. Data were collected from all healthcare facilities and also from homes and villages. A data entry template was designed in Microsoft Access and used for data capture. Alfirevic et al. defined the standard primipara as a woman in her first pregnancy, with a singleton fetus in cephalic presentation, with spontaneous onset of labour between 37 + 0 weeks and 42 + 0 weeks, with no antenatal complications or previous hospital admission lasting more than 24 h [5]. This was the definition of the standard primipara used in this study. Data from all the districts in the main study were used to extract records for women who met the definition of the standard primipara; and subsequent data analyses were performed in Stata Version 9.0 (StataCorp LP, College Station, TX). The standard primiparae were then used to compare maternal and perinatal process and outcome indicators between rural and urban, across urban and across rural districts. Pearson chi-squared test was used to determine the association between the categorical variables. The quality of obstetric care was assessed using the following indicators: a) Obstetric process indicators:Booking status (at least one antenatal visit), gestational age at booking, antenatal human immunodeficiency virus (HIV) screening rate, and initial place of onset of labour, utilisation of maternity waiting shelters in the rural districts, institutional delivery rate, intrapartum complication detection rate, and referral in labour rate, operative vaginal delivery rate, caesarean section rate and the postpartum referral rate. b) Obstetric outcome indicators:PNMR.

AI Digest

Study Justification:

– The study aimed to assess the quality of obstetric care in Zimbabwe.
– Monitoring the quality of obstetric care is essential for improving maternity services.
– There is a disparity in obstetric care and outcomes among women giving birth in different obstetric units.
– Comparing the quality of obstetric care is challenging due to population characteristics and differences in complication prevalence.
– The concept of the standard primipara was introduced as a tool to control for confounding factors and compare the quality of care among districts in Zimbabwe.

Study Highlights:

– The study used data from the Zimbabwe Maternal and Perinatal Mortality Study.
– Cluster sampling was done with provinces as clusters, and 11 districts were randomly selected.
– The study focused on the standard primipara, defined as a woman in her first pregnancy without complications, with spontaneous onset of labor at term.
– Process and outcome indicators were used to compare the quality of care between rural and urban districts, as well as across rural and urban districts.
– The study found higher perinatal mortality rates in rural districts compared to urban districts.
– Significant differences in process indicators were observed between urban-to-urban and rural-to-rural districts.

Study Recommendations:

– Further exploration is needed to improve the quality of obstetric care in rural districts of Zimbabwe.
– Strategies should be developed to address the disparities in perinatal mortality rates between rural and urban districts.
– Efforts should be made to improve process indicators in both rural and urban districts.

Key Role Players:

– Researchers and data analysts
– Healthcare providers and professionals
– Policy makers and government officials
– Community leaders and organizations
– Non-governmental organizations (NGOs) and international partners

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers
– Infrastructure improvement in healthcare facilities
– Equipment and supplies for obstetric care
– Community outreach and education programs
– Monitoring and evaluation systems
– Research and data collection expenses
– Collaboration and coordination efforts with stakeholders

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is described, and data from a large sample size were collected. The use of the standard primipara as a tool to compare the quality of obstetric care is a relevant approach. However, the abstract does not provide details on the methodology used to assess the quality of care or the statistical analysis performed. To improve the strength of the evidence, the abstract should include more information on the study methodology, such as the specific process and outcome indicators used, and provide a summary of the statistical findings.

Abstract

Zimbabwe is divided into 10 administrative Provinces, which are divided into 59 Districts. Harare, the biggest Province has urban districts only unlike all the other Provinces which are comprised of urban and rural districts. The Zimbabwe Maternal and Perinatal Mortality Study (ZMPMS) was a population-based descriptive and cross-sectional study of deaths of women in pregnancy and perinatal deaths in Zimbabwe. The study was done to estimate the maternal mortality ratio (MMR) and the perinatal mortality rate (PNMR) in Zimbabwe [8]. Data were collected from the 1st of May 2007 to the 30th April 2008. Cluster sampling was done with the 10 provinces as clusters and 11 districts were randomly selected with one from each of the 9 provinces and 2 from Harare which is the biggest province in Zimbabwe. In these 11 districts, pregnancy outcomes were collected prospectively on all women delivering after 22 weeks gestation for 11 months [8]. Data were collected from all healthcare facilities and also from homes and villages. A data entry template was designed in Microsoft Access and used for data capture. Alfirevic et al. defined the standard primipara as a woman in her first pregnancy, with a singleton fetus in cephalic presentation, with spontaneous onset of labour between 37 + 0 weeks and 42 + 0 weeks, with no antenatal complications or previous hospital admission lasting more than 24 h [5]. This was the definition of the standard primipara used in this study. Data from all the districts in the main study were used to extract records for women who met the definition of the standard primipara; and subsequent data analyses were performed in Stata Version 9.0 (StataCorp LP, College Station, TX). The standard primiparae were then used to compare maternal and perinatal process and outcome indicators between rural and urban, across urban and across rural districts. Pearson chi-squared test was used to determine the association between the categorical variables. The quality of obstetric care was assessed using the following indicators: a) Obstetric process indicators:Booking status (at least one antenatal visit), gestational age at booking, antenatal human immunodeficiency virus (HIV) screening rate, and initial place of onset of labour, utilisation of maternity waiting shelters in the rural districts, institutional delivery rate, intrapartum complication detection rate, and referral in labour rate, operative vaginal delivery rate, caesarean section rate and the postpartum referral rate. b) Obstetric outcome indicators:PNMR.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could be used to improve access to maternal health in Zimbabwe:

1. Telemedicine: Implementing telemedicine services can help bridge the gap between rural and urban districts by allowing pregnant women in remote areas to access healthcare professionals through virtual consultations. This can provide timely advice, monitoring, and support during pregnancy.

2. Mobile clinics: Setting up mobile clinics that travel to rural areas can ensure that pregnant women have access to prenatal care, including regular check-ups, screenings, and vaccinations. These clinics can also provide education on maternal health and childbirth.

3. Maternity waiting shelters: Expanding the utilization of maternity waiting shelters in rural districts can provide a safe and comfortable place for pregnant women to stay closer to healthcare facilities as they approach their due dates. This can help reduce delays in receiving timely obstetric care.

4. Community health workers: Training and deploying community health workers in rural areas can improve access to maternal health services. These workers can provide basic prenatal care, health education, and referrals to healthcare facilities when necessary.

5. Improved transportation: Enhancing transportation infrastructure and services in rural areas can ensure that pregnant women can reach healthcare facilities in a timely manner. This can involve providing ambulances or improving road networks to facilitate emergency obstetric care.

6. Strengthening referral systems: Developing and strengthening referral systems between rural and urban healthcare facilities can ensure that pregnant women with complications receive appropriate and timely care. This can involve establishing clear protocols, communication channels, and transportation arrangements for referrals.

7. Quality improvement initiatives: Implementing quality improvement initiatives in healthcare facilities can enhance the overall quality of obstetric care. This can involve training healthcare providers, improving infection control practices, and ensuring the availability of essential equipment and medications.

8. Health information systems: Implementing robust health information systems can help collect and analyze data on maternal health outcomes, enabling policymakers to identify gaps and make evidence-based decisions to improve access to maternal health services.

It’s important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and needs of Zimbabwe.

AI Innovations Description

The recommendation to improve access to maternal health based on the described study is to focus on improving the quality of obstetric care in rural districts of Zimbabwe. This can be achieved by implementing the following strategies:

1. Increase access to antenatal care: Encourage pregnant women in rural districts to attend at least one antenatal visit to ensure early detection and management of any complications.

2. Improve gestational age at booking: Promote early initiation of antenatal care to ensure timely identification and management of high-risk pregnancies.

3. Enhance antenatal HIV screening: Increase the rate of HIV screening during antenatal visits to identify and provide appropriate care for HIV-positive pregnant women.

4. Strengthen maternity waiting shelters: Improve the utilization of maternity waiting shelters in rural districts to ensure that pregnant women have a safe and supportive environment to stay in close proximity to healthcare facilities during the final weeks of pregnancy.

5. Promote institutional delivery: Encourage pregnant women to deliver in healthcare facilities to ensure access to skilled birth attendants and emergency obstetric care if needed.

6. Enhance intrapartum complication detection: Improve the capacity of healthcare providers in rural districts to detect and manage intrapartum complications promptly.

7. Strengthen referral systems: Establish effective referral systems to ensure timely transfer of pregnant women with complications to higher-level healthcare facilities.

8. Increase operative vaginal delivery and caesarean section rates: Ensure that healthcare providers in rural districts have the necessary skills and resources to perform operative vaginal deliveries and caesarean sections when indicated.

9. Improve postpartum referral: Enhance the referral process for postpartum women who require further care or treatment.

By implementing these recommendations, the quality of obstetric care in rural districts of Zimbabwe can be improved, leading to better maternal and perinatal outcomes and increased access to maternal health services.

AI Innovations Methodology

In order to improve access to maternal health in Zimbabwe, here are some potential recommendations:

1. Strengthening healthcare infrastructure: Investing in the development and improvement of healthcare facilities, particularly in rural areas, can help increase access to maternal health services. This includes ensuring the availability of well-equipped maternity units, skilled healthcare providers, and essential medical supplies.

2. Enhancing transportation systems: Improving transportation networks and providing reliable and affordable transportation options can help pregnant women in remote areas reach healthcare facilities in a timely manner. This can be achieved through initiatives such as establishing ambulance services, improving road infrastructure, and implementing community-based transportation programs.

3. Promoting community-based care: Implementing community-based maternal health programs can help bring essential healthcare services closer to pregnant women, especially in underserved areas. This can involve training and empowering community health workers to provide basic prenatal care, education, and referrals for more complex cases.

4. Increasing awareness and education: Conducting awareness campaigns and educational programs can help improve knowledge and understanding of maternal health issues among women, families, and communities. This can include promoting the importance of antenatal care, safe delivery practices, and the recognition of danger signs during pregnancy.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline data collection: Gather information on the current state of maternal health access in Zimbabwe, including indicators such as maternal mortality ratio, perinatal mortality rate, utilization of antenatal care, institutional delivery rates, and other relevant data.

2. Define simulation parameters: Determine the specific variables and factors that will be simulated, such as the increase in healthcare infrastructure, transportation improvements, community-based care interventions, and awareness campaigns. Assign values or percentages to represent the expected impact of each intervention.

3. Model development: Use statistical modeling techniques to create a simulation model that incorporates the baseline data and the defined parameters. This model should be able to simulate the impact of the recommended interventions on the selected indicators of maternal health access.

4. Simulation runs: Run the simulation model multiple times, adjusting the values of the parameters to observe different scenarios and their potential impact on improving access to maternal health. This can help identify the most effective combination of interventions and their expected outcomes.

5. Analysis and interpretation: Analyze the simulation results to assess the potential impact of the recommended interventions on improving access to maternal health. Compare the simulated scenarios to the baseline data to determine the magnitude of improvement that can be achieved.

6. Recommendations and implementation: Based on the simulation results, make recommendations for implementing the most effective interventions to improve access to maternal health in Zimbabwe. Consider factors such as feasibility, cost-effectiveness, and sustainability when developing an implementation plan.

It is important to note that simulation models are simplifications of complex systems and their results are based on assumptions and available data. Therefore, the accuracy of the simulation outcomes depends on the quality of the data and the validity of the assumptions made. Regular monitoring and evaluation of the implemented interventions are crucial to validate the simulation results and make necessary adjustments.

Author

Dima Health

Statistics:

Citations: 5

Identifiers:

DOI: 10.1186/s12884-018-1863-5

Research Areas:

Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health

Study Countries:

Zimbabwe

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female