Reducing labour-related maternal, child deaths

Study identifies poverty, facility gaps, bleeding, eclampsia as major causes of mortality

A major study commissioned by the World Health Organisation (WHO) in Nigeria and Uganda has identified poverty, facility gaps, bleeding/haemorrhage, eclampsia, lack of social health insurance scheme, non-participation of husbands (male partners), and high cost of caesarean section as the major causes of high Maternal Mortality Ration (MMR) and Perinatal Mortality Ratio (PMR) in the country.

Eclampsia is a condition in which one or more convulsions occur in a pregnant woman suffering from high blood pressure, often followed by coma and posing a threat to the health of mother and baby.

According to the WHO, the perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth. Perinatal and maternal health are closely linked. Perinatal mortality refers to the number of stillbirths and deaths in the first week of life (early neonatal mortality).

The hospital-based study on 10,000 pregnant women in Nigeria and Uganda, tagged Better Outcomes in Labour Difficulty (BOLD) project, aims to improve the quality of intra-partum care in low- and middle-income countries.

Intra-partum is the period from the onset of labour to the end of the third stage of labour.Bill and Melinda Gates Foundation funded the study by a team of researchers from the Department of Reproductive Health and Research (RHR), and Maternal and Perinatal Health & Preventing Unsafe Abortion (MPA) of the WHO; human reproduction programme (hrp) of the United Nations (UN) and World Bank; Uganda; and Nigeria.

The WHO has used the data from the BOLD Project to developed a software, electronic health solution, tagged Simplified, Effective, Labour Monitoring-to-Action (SELMA) tool, which promises to identify the essential elements of intra-partum monitoring that trigger the decision to use interventions. SELMA aimed at preventing poor labour outcomes that usually lead to the death of mother and child.

The team of researchers said SELMA is an improvement and local evidence-based alternative to partograph. A partogram or partograph is a composite graphical record of key data (maternal and fetal) during labour entered against time on a single sheet of paper. Relevant measurements might include statistics such as cervical dilation, fetal heart rate, duration of labour and vital signs.

The development of the SELMA algorithm and tool is part of the BOLD project, a larger initiative with the overall goal of reducing adverse maternal and infant outcomes resulting from labour complications through research, design and implementation of innovative tools.

The BOLD project also includes the development of a Passport for Safer Birth (PSB, another tool being developed as part of the BOLD project). The BOLD project has a qualitative, formative research component that will feed into the final development of SELMA at the implementation phase. In the future, the findings from this project may contribute to WHO guidelines on intra-partum care.

A member of the team, Dr. Bukola Fawole of the Department of Obstetrics and Gynaecology, University of Ibadan (UI), Oyo State, at the BOLD Project Dissemination Meeting in Abuja, the told The Guardian: “We have identified some challenges within our healthcare system and those challenges we believe contribute to the poor outcome that we continue to observe in our mothers and their newborn babies.

“We had identified a few challenges, a few constrains within the hospitals. We have identified that some of our hospitals particularly the newly constructed ones have space constraints in the labour wards such that it is not every woman who comes in labour are given attention, particularly those who come early are admitted immediately. Because of the constrain of space, women are asked to go back and return later and what this meeting has identified is that potentially, some of these women may have come in initially when the baby is alive and by the time they return because they have not been effectively monitored, there may have be some adverse outcomes and some might lost their baby in the process. Whereas if they have been admitted they would have been examined and labour monitored and then would have known when problems arose and intervened appropriately.

“We have also identified that causes of deaths in our women rarely have not changed; bleeding as a consequence of labour remain the leading cause of death. We also identify that disorders arising from hypertension in pregnancy also remain a major cause of death and what is painful is that these are conditions that are largely preventable even when we didn’t prevent it initially, once we identify it and we implement appropriate intervention early we should prevent such maternal deaths and we implement appropriate interventions early.”

“Our goal is to engage all stakeholders and of course I must also add that this disseminating meeting also identified that there are certain remote cases in terms of financial challenges, some social issues that prevents the women from making immediate access to health care and so the consensus is that we need a very holistic approach such that would identify these problems. Issue of finance for instance we heard in our midst colleagues coming from other foreign countries, Uganda for example where we are told that in a particular hospital they have over 30,000 deliveries in a year and that is made possible because funding has been largely eliminated so that women have easy access to care during labour. We imagine that Nigeria being more populous than Uganda that there is no reason why our own hospitals should not also have equally large deliveries. If the women and the families are enabled, if we remove the constraint of finance there, we should have higher rates of hospital-based deliveries.

“So in summary we have identified that we need to address all these causes, all these constrains both immediate and remote all the social issues, all the finance issues we must come together as a people to address them frontally so that we can reduce the number of deaths both of the mothers as well as for the babies and I must also highlight the fact that at this meeting we were completely alarmed by the high rates of deaths of babies in the womb and also deaths of the newborn, we have highlighted the fact that it is all these cause we have pointed to that prevents mothers from coming in that kills both the mother and the babies.”

WHO BOLD Research Group was led by João Paulo Souza, a Medical Officer at the WHO Department of Reproductive Health and Research and a Professor (on leave) of Social Medicine at the Ribeirão Preto Medical School, University of São Paulo, Brazil.

Other members of the team include: Prof. Olufemi T. Oladapo, a medical officer at the Department of Reproductive Health and Research WHO Geneva, Switzerland; and Dr. Livia Oliveira-Ciabati of the University of Sao Paulo.

Souza told The Guardian: “This study lead to the development of electronic tool that is designed to support decision making during labour. We hope that with this tool we will facilitate better and safer decisions concerning the management of labour. Next step? There is still research that still needs to be done and that will be done in Nigeria and in other countries next year. But we anticipate that with this tool that we will totally transform the way labour is currently managed in health facilities.

“We have developed an alternative to the partograph which is a tool that is being used for over 40 years and was originally developed from use in remote locations but we have started using it in the hospitals and that has lead to unnecessarily use of interventions. So we have medicalised too much health care.”

On the advantages of this SELMA over other tools, Souza said: “SELMA generates standards for labour progression that are personalised to the woman that it is assisting, not only that, the tool provides advice, suggestions for management of labour something that the partograph does not do currently and I think more importantly it was developed with data from Nigeria and so it is much more applicable to the women in this part of the world.

“We will have the test version that will be used in a large study next year. In November we will release it but still for testing and we hope by the end of next year it will be ready for public use.”

The professor of obstetric and gynaecology said the intent of the pantograph is to identify women at the risk of complications during labour. He further explained: “What we have seen from our data is that it over diagnose and it put too many women that are not delayed in labour, in delayed labour and it also does not capture women that are not crossing lines of the partograph. There is some parameter that is not useful. So there are sides that are not very useful for this purpose and that is what we have seen

“You can have it on your mobile phones your tablets and your computer so it is software, which could be used by Traditional Birth Attendants (TBAs) and unskilled personnel. That is actually our target in terms of developing these tools. It is for the less skilled, the TBAs and some doctors that are not specialist in obstetrics, junior doctors, medical doctors that are not specialised in obstetrics.”

Dr. Kayode Afolabi of the Division of Reproductive Health at the Federal Ministry of Health (FMoH) said: “Generally, we are looking at various innovations to improve health outcomes especially all the vulnerable groups in the community, the women and the children and we at the federal ministry of health believe we should take the advantage of informational technology and the advancement that are being made recently in that area that is why we are looking at evidence based on studies, projects, researches that could influence positively our electronic health (e-health) policy in the country.

“So I believe the BOLD Project will be one of such studies or research that could positively impact policy and practice and ultimately impact positively on the outcome of health care delivery in the country, in this particular situation with reference to management of child birth.

“Now, the challenge on maternal and reproductive health in the country is so great in such a way that statistics have it that over a 100 women die daily of childbirth in this country and the country contributes disproportionately to the global burden of maternal death. So this kind of innovative study when eventually it is concluded and if we find it useful am sure it will be of great influence on the policy on e-health in maternal and reproductive health of the country.”

Oladapo told The Guardian, who was at the dissemination meeting: “For me the main issue is what the facilities have been experiencing. It has to do with structural deficiencies that do not allow women to be monitored efficiently when they come in for labour and childbirth. You heard people talking about patient being asked to go home when they come in early labour and by the time they come back, they are already in the late stage of labour and maybe something bad might have happened at that time, something they would not be able to prevent.

“So there is a problem with the structure in the hospital where women don’t have the opportunity to stay to wait a bit when labour is still in the very first phase before they transfer them to the labour room. They only have rooms to delivery women and that is creating a problem and that is the main thing a have found here.

“The other thing is that the Nigerian team is very enthusiastic, they are open to suggestions and you could see the way they play with the tool. We went to two hospitals yesterday, I think they are doing what they can within the limits of their resources. But more importantly if we are able to develop the tool the way we plan it, it is going to transform or even revolutionalise how labour is being managed not just in Nigeria but across the world.”

When is the WHO rolling out SELMA? Oladapo said: “We need to first make sure that the tool is testable and then we will go ahead and do a proper study and test it. Hopefully we need to also get grants from other institutions because WHO does not fund everything. So depending on if we are able to get grant on time, we intend to test this against what we are using currently to see if this is better or not and if we find out this is better, then WHO will issue recommendation on the use of this tool and then roll it out and implement it. That will take another two to three years because this thing takes time. We have been on this one, to get to this stage it has been over two years.”

Senior Obstetrician and Gynaecologist at Wuse District Hospital, Abuja,Dr. Alabi Olubunmi, whose centre was also part of the study, said: “There is need for Nigerian husbands and males to participate actively especially accompany their wives to antenatal clinics and hear what the doctors and nurses are saying. With that they have the knowledge of the period when the woman is going to deliver and they should try to be available because you cannot predict which labour is going to be normal until after the woman has delivered and has gone home.

“Most of the problem we encounter is that the man is nowhere to be found and the woman is not empowered to bring out money to do the needful at the right time. Even some of them are not empowered to take decision on behalf of their husband. Peradventure if this thing is going to be operation please go ahead, keep this money. Some of them will have to go home to go and look for money, to go and look for the husband, to take permission and so on. So during this period definitely there will be delay and when there is delay is either you lose the baby if you don’t lose the woman. So men should be encouraged to actively participate, not only participate in this antenatal but also on the issue of family planning.”