Individual and health facility factors and the risk for obstructed labour and its adverse outcomes in south-western Uganda

  • BMC Pregnancy and Childbirth, Volume 11, Year 2011

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Study Justification:
The study aimed to investigate the individual and health facility factors that contribute to obstructed labor and its adverse outcomes in south-western Uganda. Obstructed labor is a significant cause of maternal morbidity and mortality, as well as adverse outcomes for newborns, particularly in low-income countries. Understanding the factors associated with obstructed labor can help inform policies and interventions to improve maternal and newborn health in the region.
Study Highlights:
– The prevalence of obstructed labor in the six hospitals studied was 10.5%.
– The main causes of obstructed labor were cephalopelvic disproportion, malpresentation or malposition, and hydrocephalus.
– Risk factors for obstructed labor included being a resident of a particular district (Isingiro), nulliparous status, having delivered once before, and being in the age group of 15-19 years.
– Adverse outcomes associated with obstructed labor included a higher risk of perinatal death and maternal complications.
– The perinatal mortality rate was higher in women with obstructed labor compared to those without the condition.
– The case fatality rate for obstructed labor was 1.2%.
Recommendations for Lay Readers and Policy Makers:
– The study findings highlight the importance of addressing individual socio-demographic and health system factors to reduce the risk of obstructed labor and its adverse outcomes.
– Policy makers should consider implementing safe motherhood programs that focus on improving access to comprehensive emergency obstetric care services, especially in districts with higher risk factors.
– Interventions should target nulliparous women, women in the age group of 15-19 years, and women residing in specific districts to reduce the risk of obstructed labor.
– Efforts should be made to improve the availability and accessibility of obstetric services, particularly in areas with limited healthcare facilities.
– Education and awareness programs should be developed to promote early recognition of obstructed labor and encourage timely seeking of healthcare services.
Key Role Players:
– Policy makers and government officials responsible for healthcare planning and resource allocation.
– Healthcare providers, including obstetricians, midwives, and nurses, who play a crucial role in the prevention, detection, and management of obstructed labor.
– Community health workers and village health teams who can help raise awareness and provide education on maternal health issues.
– Non-governmental organizations (NGOs) and international agencies that can provide support and resources for implementing interventions and programs.
Cost Items for Planning Recommendations:
– Infrastructure development: Construction or renovation of healthcare facilities to improve access to comprehensive emergency obstetric care services.
– Equipment and supplies: Procurement of medical equipment, instruments, and supplies needed for obstetric care.
– Training and capacity building: Investment in training programs for healthcare providers to enhance their skills in managing obstructed labor.
– Outreach and education: Development and implementation of community-based education and awareness programs.
– Monitoring and evaluation: Allocation of resources for monitoring and evaluating the effectiveness of interventions and programs aimed at reducing obstructed labor and its adverse outcomes.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a review of a large number of obstetric records and includes multivariate logistic regression analyses. However, to improve the evidence, the study could have included a control group of women without obstructed labour for comparison. Additionally, the study could have provided more information on the methodology used for data collection and analysis.

Background: Obstructed labour is still a major cause of maternal morbidity and mortality and of adverse outcome for newborns in low-income countries. The aim of this study was to investigate the role of individual and health facility factors and the risk for obstructed labour and its adverse outcomes in south-western Uganda.Methods: A review was performed on 12,463 obstetric records for the year 2006 from six hospitals located in south-western Uganda and 11,180 women records were analysed. Multivariate logistic regression analyses were applied to control for probable confounders.Results: Prevalence of obstructed labour for the six hospitals was 10.5% and the main causes were cephalopelvic disproportion (63.3%), malpresentation or malposition (36.4%) and hydrocephalus (0.3%). The risk of obstructed labour was statistically significantly associated with being resident of a particular district [Isingiro] (AOR 1.39, 95% CI: 1.04-1.86), with nulliparous status (AOR 1.47, 95% CI: 1.22-1.78), having delivered once before (AOR 1.57, 95% CI: 1.30-1.91) and age group 15-19 years (AOR 1.21, 95% CI: 1.02-1.45). The risk for perinatal death as an adverse outcome was statistically significantly associated with districts other than five comprising the study area (AOR 2.85, 95% CI: 1.60-5.08) and grand multiparous status (AOR 1.89, 95% CI: 1.11-3.22). Women who lacked paid employment were at increased risk of obstructed labour. Perinatal mortality rate was 142/1000 total births in women with obstructed labour compared to 65/1000 total births in women without the condition. The odds of having maternal complications in women with obstructed labour were 8 times those without the condition. The case fatality rate for obstructed labour was 1.2%.Conclusions: Individual socio-demographic and health system factors are strongly associated with obstructed labour and its adverse outcome in south-western Uganda. Our study provides baseline information which may be used by policy makers and implementers to improve implementation of safe motherhood programmes. © 2011 Kabakyenga et al; licensee BioMed Central Ltd.

A retrospective review of obstetric records was conducted in six hospitals namely Mbarara Regional Referral which also doubles as a university teaching hospital, Kitagata, Ishaka Adventist, Comboni, Ibanda, and Rushere Community located in five neighbouring districts of south-western Uganda. Table ​Table11 shows the hospitals and the district of location, locality (urban/rural), category/ownership and deliveries for the year 2006. Kitagata, Ishaka Adventists and Comboni hospitals were at the time of conducting the study located in Bushenyi district (split into 5 districts since 1st July, 2010). While the other 3 hospitals Mbarara, Ibanda, Rushere are located in Mbarara, Ibanda and Kiruhura districts respectively. Isingiro district did not have a hospital of its own and comprehensive emergency care services were sought from neighbouring Mbarara hospital. Hospitals in the study by district, location, category/ownership, and total deliveries for 2006 ºBushenyi was administratively split into 5 districts with effect from 1st July 2010 *PNFP = Private Not For Profit The districts of Mbarara, Bushenyi, Ibanda, Kiruhura, and Isingiro with a population of about one and a half million people share borders and have overall similar socio-economic and cultural conditions and use the local dialect of Runyankore as the common language. The Uganda’s health care system is structured in such way that there are corresponding health units or services at different levels of the administrative structure. The village health team (VHT) is the lowest level while a national referral hospital is the highest level of care [19,20] as shown in Table ​Table22. Comprehensive emergency obstetric care services, especially operative delivery and blood transfusion, are available in all general, regional referral and national referral hospitals. According to our knowledge all the hospitals in the study were by structure able to offer a full range of comprehensive emergency obstetric care services at all times. Services offered in public hospital are officially free of charge although due to frequent shortages of drugs/supplies, patients/clients are requested to procure missing items from private pharmacies. Mbarara and Ibanda hospitals were the two hospitals with specialists (Obstetricians) while the other hospitals had general doctors as their highest ranked clinicians. Structure of Uganda national health system Adapted from Government of Uganda Health Strategic Plan II, 2005/06-2009/10 [19] & Rutebemberwa et al., 2009 [20] Twelve thousand four hundred and sixty three (12,463) obstetric records of women who were admitted in the maternity wards of the six hospitals (Mbarara, Kitagata, Ishaka, Comboni and Ibanda) from January 1 through December 31, 2006 were reviewed. The data collectors were midwives proficiently trained to collect data from women’s obstetric files or charts and to validate the diagnosis of obstructed labour using admission, delivery and theatre registers. Data was recorded in case record forms developed by the researchers and pre-tested on 200 maternity records for the year 2007. The case record was modified to correct observed inconsistencies. The case record form was designed to collect data on socio-demographic variables, labour, delivery and post-delivery periods. Computer data entry was performed using Epidata (Epidata Association, Denmark). The criteria we used for diagnosing obstructed labour in this study was admission to a hospital with a pregnancy of a gestational age of 28 weeks or more and having a clinical diagnosis of obstructed labour in the patient chart or having an operative intervention (i.e. vaginal or abdominal) for failed progress of labour due to cephalopelvic disproportion, malpresentation or malposition. Women for whom the diagnosis of obstructed labour could not be ascertained were classified as non-obstructed labour and still included in the study sample. Women who were admitted post-partum (n = 114) were excluded from the sample, as well as women whose gestational age was < 28 weeks upon admittance or were recorded as abortion (n = 482 women), and women who were discharged before delivery (n = 687 women). This reduced the number of records included in the sample from 12,463 to 11,180. Obstructed labour was classified as: "with obstructed labour" or "no obstructed labour" Cause of obstructed labour was classified as: "cephalopelvic disproportion", "malpresentation" or "malposition" as stated in obstetric file or chart. Neonatal outcome was classified as: "live birth" or "stillbirth" Maternal outcome was classified as: "alive" or "died in hospital" Maternal complications: coded as "Yes" (if a woman had at least one complication during labour or childbirth) otherwise coded "No" Perinatal mortality rate was defined as "stillbirths and deaths in the first week per 1000 total births (live births plus stillbirths)". Age of the woman was divided into 3 age groups: 15-19, 20-29 and ≥30 years. The age range was 15 to 49 years. The age group 20-29 years was taken as the reference age group. Parity was classified into 4 groups: "0" (nulliparous), "1", "2-4", "≥5". Parity 2-4 was taken as reference category, as it is considered to be the one with minimal risk of obstructed labour. Place of residence was defined as districts of residence, which were: "Mbarara", "Bushenyi", "Ibanda", "Isingiro", "Kiruhura" and other districts (districts other than the ones specified). Bushenyi district was used as a reference district since at the time of the study it was the only district with 3 hospitals, thus providing more accessibility to emergency comprehensive services required in cases of obstructed labour. Occupation of mother was classified as: "salaried employee", "subsistence farmer", "housewife". Salaried employee group was used as a reference group on the assumption that salaried women would be in the position to have financial resources to access health care services faster. In this study only occupation is used as a proxy for socio-economic status as most of the records were missing education information regarding levels attained by women. Health facility attended: Comboni hospital, Ibanda hospital, Ishaka Adventist hospital, Kitagata hospital, Mbarara regional referral hospital, Rushere Community Hospital. Mbarara regional referral hospital being a university teaching hospital was expected to offer a high level of care and thus was therefore used as a reference hospital in this study. Women seeking obstetric services in one hospital are expected to be more similar than women who visit other hospitals for the same service. Therefore SVY routines (Stata Version 10 Software) for handling correlated data were utilised to estimate proportions (%) and 95% confidence intervals of women who had obstructed labour and its outcomes (perinatal death and maternal complications). Crude Odds Ratios (COR), Adjusted Odds Ratios (AOR) and their 95% confidence intervals (CI) were calculated by means of multivariate logistic regression analysis taking into consideration the clustering of women at the hospital level. The mixed effects model was applied to determine the adjusted effects of age, parity, and residence on perinatal death and maternal complications among women who experienced obstructed labour assuming a random intercept. It was assumed that hospitals would have different intercepts due to differences in the level of care and some unmeasured health system factors. However the effect of the studied covariates was expected to be similar across hospitals. Cases with missing values were excluded from these analyses. Data was analysed using STATA version 9 (STATA Corporation, College Texas USA). Ethical clearance was applied and granted from Uganda National Council of Science and Technology and from Lund University, Sweden. Permission to access obstetric records was obtained from respective medical superintendents of the hospitals included in our study.

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

1. Telemedicine: Implementing telemedicine services can provide remote access to healthcare professionals, allowing pregnant women in remote areas to receive medical advice and consultations without having to travel long distances.

2. Mobile clinics: Setting up mobile clinics that travel to rural areas can bring healthcare services closer to pregnant women who may not have easy access to healthcare facilities. These clinics can provide prenatal care, screenings, and basic obstetric services.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in their communities. These workers can also help identify high-risk pregnancies and refer women to appropriate healthcare facilities.

4. Birth preparedness and emergency readiness: Implementing programs that educate pregnant women and their families about the importance of planning for childbirth and emergencies. This can include creating birth plans, identifying transportation options, and ensuring access to emergency obstetric care.

5. Improving infrastructure: Investing in the improvement of healthcare infrastructure, including the construction and equipping of maternal health facilities in underserved areas. This can help ensure that pregnant women have access to quality obstetric care closer to their homes.

6. Financial incentives: Providing financial incentives, such as transportation vouchers or cash transfers, to pregnant women who attend prenatal care visits or deliver at healthcare facilities. This can help reduce financial barriers and encourage women to seek timely and appropriate care.

7. Health information systems: Implementing electronic health records and data collection systems to improve the tracking and monitoring of maternal health indicators. This can help identify gaps in care, monitor progress, and inform decision-making for targeted interventions.

It is important to note that the specific context and needs of the community should be considered when implementing any innovation to improve access to maternal health.
AI Innovations Description
Based on the study conducted in south-western Uganda, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening healthcare facilities: Improve the infrastructure and resources of healthcare facilities in south-western Uganda to ensure they are equipped to provide comprehensive emergency obstetric care services, including operative delivery and blood transfusion. This can be done by providing necessary medical equipment, supplies, and trained healthcare professionals.

2. Enhancing transportation services: Develop a reliable and efficient transportation system to ensure that pregnant women can access healthcare facilities in a timely manner. This can include providing ambulances or other means of transportation to transport women in need of emergency obstetric care.

3. Increasing awareness and education: Conduct community-based awareness campaigns to educate women and their families about the importance of antenatal care, the signs of obstructed labor, and the need for timely medical intervention. This can help reduce delays in seeking healthcare and increase awareness about the available services.

4. Addressing socio-economic factors: Implement interventions to address socio-economic factors that contribute to obstructed labor, such as poverty and lack of employment. This can include providing financial support or incentives for women to seek antenatal care and deliver in healthcare facilities.

5. Strengthening referral systems: Improve the coordination and communication between healthcare facilities at different levels to ensure timely referrals and transfers of pregnant women in need of specialized care. This can involve establishing clear referral protocols and training healthcare providers on their implementation.

By implementing these recommendations, access to maternal health can be improved in south-western Uganda, leading to a reduction in the prevalence of obstructed labor and its adverse outcomes.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Strengthening healthcare infrastructure: Investing in the construction and renovation of healthcare facilities, particularly in districts with limited access to maternal health services, can help improve access to obstetric care.

2. Increasing skilled healthcare providers: Training and deploying more skilled healthcare providers, such as obstetricians and midwives, to areas with high rates of obstructed labor can ensure that women receive timely and appropriate care.

3. Enhancing transportation services: Improving transportation infrastructure and providing ambulances or other means of transportation can help women in remote areas reach healthcare facilities quickly during emergencies.

4. Promoting community awareness and education: Conducting community awareness campaigns and providing education on the importance of antenatal care, early recognition of complications, and timely access to healthcare services can empower women and their families to seek appropriate care.

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

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the number of women receiving antenatal care, the proportion of women delivering in healthcare facilities, and the maternal mortality rate.

2. Collect baseline data: Gather data on the current status of the indicators in the target area. This can be done through surveys, interviews, and analysis of existing health records.

3. Develop a simulation model: Create a simulation model that incorporates the potential impact of the recommendations on the identified indicators. This model should consider factors such as population size, healthcare infrastructure, availability of skilled providers, and transportation services.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of each recommendation. Adjust the parameters of the model based on the expected effects of the recommendations.

5. Analyze results: Analyze the simulation results to determine the potential impact of each recommendation on the indicators of access to maternal health. Compare the results to identify the most effective interventions.

6. Refine and validate the model: Refine the simulation model based on feedback from experts and stakeholders. Validate the model by comparing the simulated results with real-world data, if available.

7. Communicate findings: Present the findings of the simulation study to policymakers, healthcare providers, and other stakeholders. Use the results to advocate for the implementation of the most effective recommendations to improve access to maternal health.

It is important to note that the methodology described above is a general framework and can be customized based on the specific context and available data.


Statistics:
Citations: 35
Identifiers:
DOI: 10.1186/1471-2393-11-73
Research Areas:
Community Interventions, 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:
Uganda
Study Design:
Cohort Study, Cross Sectional Study, randomised-control-trial
Study Approach:
Quantitative
Participants Gender:
Female
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