Maternal near-miss and death and their association with caesarean section complications: A cross-sectional study at a university hospital and a regional hospital in Tanzania

BMC Pregnancy and Childbirth, Volume 14, No. 1, Year 2014

Interpretation

Background: The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications.Methods: We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital in Dar es Salaam, Tanzania. Cases were assessed individually to determine their association with CS. Main outcome measures included MNM ratio; maternal mortality ratio; proportion of MNM and death associated with CS complications; and the risk for such outcomes per 1,000 operations. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was calculated.Results: We identified 467 MNM events and 77 maternal deaths. The MNM ratio was 36 per 1,000 live births (95% CI 33-39) and the maternal mortality ratio was 587 per 100,000 live births (95% CI 460-730). Major causes were eclampsia and postpartum haemorrhage, but we also detected nine MNM events and five deaths from iatrogenic complications. CS complications accounted for 7.9% (95% CI 5.6-11) of the MNM events and 13% (95% CI 6.4-23) of the maternal deaths. The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital (22/1,000 operations, 95% CI 12-37) compared to the university hospital (7.0/1,000 operations, 95% CI 3.8-12) (risk ratio 3.2, 95% CI 1.5-6.6).Conclusions: The occurrence of MNM and death at the two hospitals was high, and many cases were associated with CS complications. The maternal risks of CS in low-resource settings must not be overlooked, and measures should be taken to avoid unnecessary CSs. More comprehensive training of staff, improved postoperative surveillance, and a more even distribution of resources within the health care system might reduce the risks of CS. We conducted a cross-sectional study at one university hospital and one regional hospital in Dar es Salaam, Tanzania, between February and June 2012. Obstetric and gynaecological wards were visited every second day by the main researcher (HL) and all medical records of admitted patients were reviewed in order to identify cases. The record books in which midwives document severe cases were also examined. Data on demographic and clinical characteristics were collected from medical records and antenatal cards. Maternal death files, routinely gathered by hospital staff, were reviewed monthly. Cases in which the underlying cause of MNM or death was unclear were discussed between three of the authors (HL, HK, and MA) and guidance was sought in the International Statistical Classification of Diseases and Related Health problems-Maternal Mortality [21]. As the exact chain of events was sometimes difficult to follow due to a lack of information from referring institutions, the leading cause of MNM or death was considered to be the diagnosis that most likely had put the woman in a life-threatening condition. Our definition thereby deviated from the international classification system of maternal deaths, where the underlying cause is defined as the disease or condition that initiated the morbid chain of events leading to a woman’s death [21]. Data on total number of deliveries, live births, and CSs were derived from the obstetric database at the university hospital and the birth register at the regional hospital. Tanzania is a low-income country with high maternal and perinatal mortality [22]. It is the policy of the government to provide maternity care free of charge. The country’s latest Demographic and Health Survey estimated the total fertility rate to 5.4 children per woman; the national CS rate to 5.0%; and the MMR to 454 maternal deaths per 100,000 live births (95% confidence interval [CI] 353–556) [22]. Due to a shortage of qualified medical doctors, Tanzania has been training non-physician clinicians, so-called assistant medical officers, since the 1960s [23]. These are secondary-school graduates who receive a total of five years of medical education, which allows them to make diagnoses, write prescriptions, and practise medicine, surgery, and anaesthesiology [23]. Dar es Salaam is the largest city in the country, with an estimated four million inhabitants [24]. Most residents live within ten kilometres of a health care facility, and 90% of all deliveries are attended by skilled personnel [22]. The public hospitals in Dar es Salaam include one university hospital, which serves as a teaching and referral institution, three regional hospitals, and one military hospital. The health care system has a hierarchical structure, where the majority of deliveries take place at health centres and regional hospitals. After an upgrade of the peripheral hospitals in the in the early 21st century, access to CSs has increased at these facilities. There are, however, still large discrepancies in the CS rates between the university hospital and the peripheral hospitals. In order to understand the MNM panorama on different levels, we conducted our study at the university hospital and in one of the regional hospitals. As the largest public hospital in the country, the university hospital handles about 9,000 deliveries annually. The obstetric department is well-staffed, with one specialist obstetrician, two residents, and one intern doctor on call each day. Patients with critical conditions are admitted to the Eclampsia Ward, where their vital signs are monitored hourly. In the main intensive care unit, treatment with vaso-active drugs and ventilation can be provided. Blood for transfusions is supplied through the hospital’s blood bank, but is sometimes insufficient and must be supplemented by the National Blood Bank. The CS rate in 2011 was 49% and instrumental deliveries constituted around 1% of the total deliveries [15]. The majority of CSs are performed by residents (medical doctors doing their specialist training) in obstetrics and gynaecology in one of the department’s two own operating theatres. Anaesthesia is provided by nurse anaesthetic assistants (qualified nurses trained in anaesthesia) or residents in anaesthesia. There are a few licensed anaesthesiologists, who mainly work as supervisors. The regional hospital is situated in the outskirts of Dar es Salaam. With regard to obstetric population and available resources, it is representative of the other two regional hospitals in the area. About 20,000 deliveries are performed annually. During the study period, two specialists in obstetrics and gynaecology, seven registrars (medical doctors working after completing their internship but before starting specialist training), and eleven assistant medical officers worked in the obstetric and gynaecological wards. There is a conspicuous shortage of equipment, including gloves, syringes, Oxytocin, and electricity. Laboratory services are rarely available. The Eclampsia Ward admits patients with eclampsia and other severe conditions. Magnesium sulphate is usually in stock. Blood for transfusions is provided by the National Blood Bank, which allocates a few units to the hospital every day. As there is only one operating theatre serving the entire hospital, the facilities cannot meet the demands for CS and patients are occasionally referred to the university hospital for surgery. CSs are performed by registrars or assistant medical officers. Anaesthesia is provided by nurse anaesthetic assistants or assistant medical officers. We included MNM events based on the WHO criteria [2, 25] and maternal deaths according to the WHO definition [21] among all women with complications during pregnancy, childbirth, or within 42 days after termination of pregnancy. A near-miss criterion was considered fulfilled if stated in the medical record or if it could be observed by the researcher, e.g. hyperventilation, repeated fits, or jaundice in the presence of pre-eclampsia. Due to limited resources, some laboratory- and management-based criteria were not applicable. As we hoped to include patients on the clinical criteria and wanted to make results as comparable as possible with other studies, we did not modify the criteria. The definitions of the criteria, their applicability in the two settings, and how we interpreted them are presented in Table A1, Additional file 1. For example, we interpreted the criterion “uncontrollable fits” as unconsciousness and repeated fits. We followed women during hospitalization until their discharge or death. Once women were discharged, they were considered to have survived. Women who were re-admitted to one of the study sites within 42 days after termination of pregnancy and died, were recorded as maternal deaths. Referrals from the regional hospital to the university hospital were presented in the data for the university hospital. Women who experienced two unrelated MNM events, such as eclampsia and infection, were recorded as two events. In order to identify women who had experienced a MNM event or death due to a CS complication, we assessed the files of all women who had fulfilled their first MNM criterion or died after having a CS, or had a diagnosis that implied a CS complication. All cases potentially associated with CS were reviewed by four of the authors (HL, KH, MR, and BE) to reach a consensus on whether they were associated with the CS or not. In the assessment, the indication of CS, the timing of MNM or death, and any pre-existing conditions were taken into account. The association between MNM or death and CS was graded as strong, moderate, or weak. Strong associations were complications specific to surgery or anaesthesia, for example damage to intra-abdominal organs. Complications not specific to surgery or anaesthesia, but with an increased risk after CS (e.g. postpartum haemorrhage leading to shock, hysterectomy, blood transfusion, or death [13, 16–18]), were considered moderate associations. Moderate associations also included cases where there was a pre-existing condition that might have affected the outcome, such as severe pre-eclampsia predisposing the woman to intra-abdominal haemorrhage after CS. Weak associations were cases in which it was unlikely that the CS complication itself had caused the MNM event or death. Data was computerised using Excel and analysed with SPSS. We calculated the MNM ratio (MNMR), defined as the number of MNM events per 1,000 live births, and the MMR, defined as the number of maternal deaths per 100,000 live births. Since many patients at the university hospital had been referred after being delivered at other hospitals, we also calculated the MNMR and MMR for women delivered only at the university hospital and only at the regional hospital, excluding women delivered elsewhere. The mortality index was calculated by dividing the number of maternal deaths by the sum of MNM events and maternal deaths [25]. The proportion of MNM and death attributed to CS complications was calculated by dividing the number of MNM events and deaths with strong or moderate association with CS by the total number of MNM events and deaths at the two hospitals. To estimate the risk of CS complications per 1,000 operations, we divided the number of MNM events and deaths with strong or moderate association with CS by the total number of CSs at the two facilities. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was also calculated. For all estimates, we computed the 95% CI. Clearance to conduct the study was obtained from the Ethics Board at Muhimbili University for Health and Allied Sciences (reference number MU/RP/AEC/Vol. XIII) on 23 December 2011. A research permit was given by the Tanzania Commission for Science and Technology (reference number 2012-39-NA-2011-191) on 17 February 2012. Permission to collect data was obtained from the administrations at Muhimbili National Hospital and Temeke Hospital. Informed consent from patients to use the information was not obtained. Data entered into the database was coded and rendered anonymous as to patient identity.

AI Digest

Study Justification:

– The study aimed to assess the occurrence and panorama of maternal near-miss (MNM) and death in low-resource settings, specifically in two hospitals in Tanzania.
– The study also aimed to explore the association between MNM and death with caesarean section (CS) complications.
– The study was conducted to highlight the potential serious effects of increasing CS rates on maternal health in low- and middle-income countries.

Study Highlights:

– The study identified 467 MNM events and 77 maternal deaths.
– The MNM ratio was 36 per 1,000 live births, and the maternal mortality ratio was 587 per 100,000 live births.
– Eclampsia and postpartum hemorrhage were the major causes of MNM and death, but iatrogenic complications were also detected.
– CS complications accounted for 7.9% of the MNM events and 13% of the maternal deaths.
– The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital compared to the university hospital.

Recommendations for Lay Reader and Policy Maker:

– Measures should be taken to avoid unnecessary CSs in low-resource settings.
– More comprehensive training of staff is needed to improve the management of CS complications.
– Improved postoperative surveillance is necessary to detect and manage CS complications promptly.
– Resources within the healthcare system should be distributed more evenly to reduce the risks of CS complications.

Key Role Players Needed to Address Recommendations:

– Healthcare providers: Obstetricians, gynecologists, anesthesiologists, nurse anesthetic assistants, assistant medical officers.
– Hospital administrators: Responsible for allocating resources and implementing training programs.
– Policy makers: Responsible for developing policies and guidelines to reduce unnecessary CSs and improve maternal healthcare.

Cost Items to Include in Planning Recommendations:

– Comprehensive training programs for healthcare providers.
– Improved postoperative surveillance systems.
– Distribution of resources to ensure equitable access to healthcare services.
– Upgrading equipment and supplies in hospitals.
– Blood transfusion services and availability of necessary medications.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on a cross-sectional study conducted at two hospitals in Tanzania. The study includes a large sample size of 467 MNM events and 77 maternal deaths, and provides specific measures such as the MNM ratio, maternal mortality ratio, and the proportion of MNM and death associated with CS complications. The study also calculates the risk of experiencing a life-threatening CS complication and compares it between the university hospital and the regional hospital. The evidence could be further strengthened by providing more details on the methodology, such as the inclusion and exclusion criteria, data collection methods, and statistical analysis techniques.

Abstract

We conducted a cross-sectional study at one university hospital and one regional hospital in Dar es Salaam, Tanzania, between February and June 2012. Obstetric and gynaecological wards were visited every second day by the main researcher (HL) and all medical records of admitted patients were reviewed in order to identify cases. The record books in which midwives document severe cases were also examined. Data on demographic and clinical characteristics were collected from medical records and antenatal cards. Maternal death files, routinely gathered by hospital staff, were reviewed monthly. Cases in which the underlying cause of MNM or death was unclear were discussed between three of the authors (HL, HK, and MA) and guidance was sought in the International Statistical Classification of Diseases and Related Health problems-Maternal Mortality [21]. As the exact chain of events was sometimes difficult to follow due to a lack of information from referring institutions, the leading cause of MNM or death was considered to be the diagnosis that most likely had put the woman in a life-threatening condition. Our definition thereby deviated from the international classification system of maternal deaths, where the underlying cause is defined as the disease or condition that initiated the morbid chain of events leading to a woman’s death [21]. Data on total number of deliveries, live births, and CSs were derived from the obstetric database at the university hospital and the birth register at the regional hospital. Tanzania is a low-income country with high maternal and perinatal mortality [22]. It is the policy of the government to provide maternity care free of charge. The country’s latest Demographic and Health Survey estimated the total fertility rate to 5.4 children per woman; the national CS rate to 5.0%; and the MMR to 454 maternal deaths per 100,000 live births (95% confidence interval [CI] 353–556) [22]. Due to a shortage of qualified medical doctors, Tanzania has been training non-physician clinicians, so-called assistant medical officers, since the 1960s [23]. These are secondary-school graduates who receive a total of five years of medical education, which allows them to make diagnoses, write prescriptions, and practise medicine, surgery, and anaesthesiology [23]. Dar es Salaam is the largest city in the country, with an estimated four million inhabitants [24]. Most residents live within ten kilometres of a health care facility, and 90% of all deliveries are attended by skilled personnel [22]. The public hospitals in Dar es Salaam include one university hospital, which serves as a teaching and referral institution, three regional hospitals, and one military hospital. The health care system has a hierarchical structure, where the majority of deliveries take place at health centres and regional hospitals. After an upgrade of the peripheral hospitals in the in the early 21st century, access to CSs has increased at these facilities. There are, however, still large discrepancies in the CS rates between the university hospital and the peripheral hospitals. In order to understand the MNM panorama on different levels, we conducted our study at the university hospital and in one of the regional hospitals. As the largest public hospital in the country, the university hospital handles about 9,000 deliveries annually. The obstetric department is well-staffed, with one specialist obstetrician, two residents, and one intern doctor on call each day. Patients with critical conditions are admitted to the Eclampsia Ward, where their vital signs are monitored hourly. In the main intensive care unit, treatment with vaso-active drugs and ventilation can be provided. Blood for transfusions is supplied through the hospital’s blood bank, but is sometimes insufficient and must be supplemented by the National Blood Bank. The CS rate in 2011 was 49% and instrumental deliveries constituted around 1% of the total deliveries [15]. The majority of CSs are performed by residents (medical doctors doing their specialist training) in obstetrics and gynaecology in one of the department’s two own operating theatres. Anaesthesia is provided by nurse anaesthetic assistants (qualified nurses trained in anaesthesia) or residents in anaesthesia. There are a few licensed anaesthesiologists, who mainly work as supervisors. The regional hospital is situated in the outskirts of Dar es Salaam. With regard to obstetric population and available resources, it is representative of the other two regional hospitals in the area. About 20,000 deliveries are performed annually. During the study period, two specialists in obstetrics and gynaecology, seven registrars (medical doctors working after completing their internship but before starting specialist training), and eleven assistant medical officers worked in the obstetric and gynaecological wards. There is a conspicuous shortage of equipment, including gloves, syringes, Oxytocin, and electricity. Laboratory services are rarely available. The Eclampsia Ward admits patients with eclampsia and other severe conditions. Magnesium sulphate is usually in stock. Blood for transfusions is provided by the National Blood Bank, which allocates a few units to the hospital every day. As there is only one operating theatre serving the entire hospital, the facilities cannot meet the demands for CS and patients are occasionally referred to the university hospital for surgery. CSs are performed by registrars or assistant medical officers. Anaesthesia is provided by nurse anaesthetic assistants or assistant medical officers. We included MNM events based on the WHO criteria [2, 25] and maternal deaths according to the WHO definition [21] among all women with complications during pregnancy, childbirth, or within 42 days after termination of pregnancy. A near-miss criterion was considered fulfilled if stated in the medical record or if it could be observed by the researcher, e.g. hyperventilation, repeated fits, or jaundice in the presence of pre-eclampsia. Due to limited resources, some laboratory- and management-based criteria were not applicable. As we hoped to include patients on the clinical criteria and wanted to make results as comparable as possible with other studies, we did not modify the criteria. The definitions of the criteria, their applicability in the two settings, and how we interpreted them are presented in Table A1, Additional file 1. For example, we interpreted the criterion “uncontrollable fits” as unconsciousness and repeated fits. We followed women during hospitalization until their discharge or death. Once women were discharged, they were considered to have survived. Women who were re-admitted to one of the study sites within 42 days after termination of pregnancy and died, were recorded as maternal deaths. Referrals from the regional hospital to the university hospital were presented in the data for the university hospital. Women who experienced two unrelated MNM events, such as eclampsia and infection, were recorded as two events. In order to identify women who had experienced a MNM event or death due to a CS complication, we assessed the files of all women who had fulfilled their first MNM criterion or died after having a CS, or had a diagnosis that implied a CS complication. All cases potentially associated with CS were reviewed by four of the authors (HL, KH, MR, and BE) to reach a consensus on whether they were associated with the CS or not. In the assessment, the indication of CS, the timing of MNM or death, and any pre-existing conditions were taken into account. The association between MNM or death and CS was graded as strong, moderate, or weak. Strong associations were complications specific to surgery or anaesthesia, for example damage to intra-abdominal organs. Complications not specific to surgery or anaesthesia, but with an increased risk after CS (e.g. postpartum haemorrhage leading to shock, hysterectomy, blood transfusion, or death [13, 16–18]), were considered moderate associations. Moderate associations also included cases where there was a pre-existing condition that might have affected the outcome, such as severe pre-eclampsia predisposing the woman to intra-abdominal haemorrhage after CS. Weak associations were cases in which it was unlikely that the CS complication itself had caused the MNM event or death. Data was computerised using Excel and analysed with SPSS. We calculated the MNM ratio (MNMR), defined as the number of MNM events per 1,000 live births, and the MMR, defined as the number of maternal deaths per 100,000 live births. Since many patients at the university hospital had been referred after being delivered at other hospitals, we also calculated the MNMR and MMR for women delivered only at the university hospital and only at the regional hospital, excluding women delivered elsewhere. The mortality index was calculated by dividing the number of maternal deaths by the sum of MNM events and maternal deaths [25]. The proportion of MNM and death attributed to CS complications was calculated by dividing the number of MNM events and deaths with strong or moderate association with CS by the total number of MNM events and deaths at the two hospitals. To estimate the risk of CS complications per 1,000 operations, we divided the number of MNM events and deaths with strong or moderate association with CS by the total number of CSs at the two facilities. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was also calculated. For all estimates, we computed the 95% CI. Clearance to conduct the study was obtained from the Ethics Board at Muhimbili University for Health and Allied Sciences (reference number MU/RP/AEC/Vol. XIII) on 23 December 2011. A research permit was given by the Tanzania Commission for Science and Technology (reference number 2012-39-NA-2011-191) on 17 February 2012. Permission to collect data was obtained from the administrations at Muhimbili National Hospital and Temeke Hospital. Informed consent from patients to use the information was not obtained. Data entered into the database was coded and rendered anonymous as to patient identity.

Materials

Innovations

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

1. Telemedicine: Implementing telemedicine technology to provide remote consultations and support for healthcare providers in low-resource settings. This can help improve access to specialized care and reduce the need for unnecessary referrals.

2. Mobile health (mHealth) applications: Developing mobile applications that provide pregnant women with information, reminders, and access to healthcare services. These apps can also facilitate communication between healthcare providers and patients, allowing for remote monitoring and support.

3. Task-shifting: Training and empowering non-physician healthcare workers, such as assistant medical officers, to perform certain tasks traditionally done by doctors. This can help address the shortage of qualified medical doctors and improve access to essential maternal healthcare services.

4. Improved postoperative surveillance: Implementing systems and protocols to closely monitor women after cesarean sections, including regular check-ups, vital sign monitoring, and early detection of complications. This can help reduce the risk of life-threatening complications and improve maternal outcomes.

5. Comprehensive training of staff: Providing comprehensive training programs for healthcare providers, including obstetricians, midwives, and nurses, to enhance their skills and knowledge in managing maternal health complications. This can help ensure that healthcare providers are equipped to handle emergencies and provide quality care.

6. Strengthening healthcare infrastructure: Investing in the improvement of healthcare facilities, including the availability of essential equipment, supplies, and medications. This can help ensure that healthcare providers have the necessary resources to provide safe and effective maternal healthcare.

7. Community-based interventions: Implementing community-based programs that focus on educating and empowering women and their families about maternal health. This can include antenatal and postnatal care education, birth preparedness, and emergency planning, as well as promoting the importance of skilled birth attendants.

These innovations can help address the challenges and improve access to maternal health in low-resource settings, ultimately reducing maternal morbidity and mortality rates.

AI Innovations Description

The recommendation to improve access to maternal health based on the study findings is to take measures to avoid unnecessary caesarean sections (CS) and reduce the risks associated with CS complications. This can be achieved through:

1. Comprehensive training of staff: Provide training to healthcare providers on appropriate indications for CS and the management of CS complications. This will ensure that CS is only performed when necessary and that healthcare providers are equipped to handle any complications that may arise.

2. Improved postoperative surveillance: Implement a system for close monitoring and follow-up of women who undergo CS. This will help identify and address any complications early on, reducing the risk of adverse outcomes.

3. Even distribution of resources: Ensure that resources, such as equipment, medications, and blood supplies, are distributed evenly across healthcare facilities. This will help prevent shortages and ensure that all facilities are adequately equipped to handle CS and manage any complications.

By implementing these recommendations, access to maternal health can be improved by reducing the risks associated with CS and ensuring that women receive appropriate and timely care.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Increase comprehensive training of healthcare staff: Providing more comprehensive training to healthcare staff, including doctors, nurses, and midwives, can help improve their skills and knowledge in managing maternal health complications. This can include training on identifying and managing CS complications, as well as other life-threatening conditions during pregnancy and childbirth.

2. Improve postoperative surveillance: Implementing better postoperative surveillance systems can help identify and address complications arising from CS procedures promptly. This can involve regular monitoring of vital signs, conducting follow-up visits, and providing necessary support and interventions to prevent adverse outcomes.

3. Enhance distribution of resources within the healthcare system: Ensuring a more even distribution of resources, such as medical equipment, medications, and skilled healthcare providers, across different healthcare facilities can help improve access to quality maternal healthcare. This can involve prioritizing resource allocation to low-resource settings and addressing disparities in healthcare infrastructure and staffing.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define key indicators: Identify key indicators that reflect access to maternal health, such as maternal mortality ratio, maternal near-miss ratio, proportion of CS complications, and risk of life-threatening CS complications.

2. Collect baseline data: Gather baseline data on the identified indicators from the target healthcare facilities or population. This can involve reviewing medical records, conducting surveys, and analyzing existing data sources.

3. Implement interventions: Introduce the recommended interventions, such as comprehensive training of healthcare staff, improved postoperative surveillance, and enhanced resource distribution. Ensure that these interventions are implemented consistently and effectively.

4. Monitor and collect data: Continuously monitor the implementation of interventions and collect data on the identified indicators. This can involve regular data collection from medical records, surveys, and other relevant sources.

5. Analyze data: Analyze the collected data to assess the impact of the interventions on the identified indicators. Compare the post-intervention data with the baseline data to determine any changes or improvements.

6. Evaluate and adjust: Evaluate the effectiveness of the interventions based on the analysis of data. Identify any gaps or areas for improvement and make necessary adjustments to the interventions or implementation strategies.

7. Repeat the process: Continuously repeat the process of monitoring, collecting data, analyzing, evaluating, and adjusting to ensure ongoing improvement in access to maternal health.

By following this methodology, it is possible to simulate the impact of the recommended interventions on improving access to maternal health and make evidence-based decisions for further improvements.

Author

Dima Health

Statistics:

Citations: 53

Identifiers:

DOI: 10.1186/1471-2393-14-244

Research Areas:

Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Tanzania

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female