Added: Xavia Stearns - Date: 17.08.2021 07:03 - Views: 30302 - Clicks: 9561
Metrics details. The inequity in emergency obstetric care access in Tanzania is unsatisfactory. Despite an existing national obstetric referral system, many birthing women bypass referring facilities and go directly to higher-level care centres.
We wanted to compare Caesarean section CS rates among women formally referred to a tertiary care centre versus self-referred women, and to assess the effect of referral status on adverse outcomes after CS. We used data from 21, deliveries, drawn from the birth registry of a tertiary hospital in northeastern Tanzania, during Referral status was categorized as self-referred if the woman had bypassed or not accessed referral, or formally-referred if referred by a health worker.
Because CS indications were insufficiently registered, we applied the Ten-Group Classification System to determine the CS rate by obstetric group and referral status. Associations between referral status and adverse outcomes after CS delivery were analysed using multiple regression models. Referral status contributed substantially to the CS rate, which was In both groups, term nulliparous singleton cephalic pregnancies and women with scar s constituted two thirds of CS deliveries.
Low Apgar score adjusted OR 1. Early neonatal death rates after CS were 1. Women referred for delivery had higher CS rates and poorer neonatal outcomes, suggesting that the formal referral system successfully identifies high-risk birth, although low volume suggests underutilization. High absolute rates of post-CS adverse outcomes among breech, multiple gestation and preterm deliveries suggest the need to target self-referred birthing women for earlier professional intrapartum care. Peer Review reports. Progress towards Millennium Development Goals MDGs 4 and 5, to reduce child and maternal mortality and morbidity, is unsatisfactory in most sub-Saharan countries [ 12 ].
It is widely acknowledged that improved and equal access to emergency obstetric care is crucial in addressing survival [ 3 — 5 ]. This is below the minimum recommended level, reflecting considerable unmet needs for emergency obstetric care [ 7 — 9 ]. Where a large proportion of births take place outside facilities, an effective referral system is necessary, but not sufficient, to achieve equitable access to emergency obstetric care.
Although a national referral system with standard criteria for referral of Looking for women in Bergsjo complications in women in need of hospital delivery is implemented in Tanzania, bypass of referring facilities 'self-referral' is a familiar phenomenon [ 1112 ]. Although more than double the national average, the rate does not disclose whether or not the interventions target those who need them and is no guarantee for equity in access to care [ 13 ]. We wanted to compare CS rates among women formally referred for hospital delivery versus self-referred women.
A secondary objective was to assess risk of adverse maternal and neonatal outcomes after CS according to referral status. As indications for CS were insufficiently registered, we applied the Ten-Group Classification System [ 14 ] to identify risk groups for targeted intervention.
We used data from the medical birth registry at the zonal referral hospital KCMC in northeastern Tanzania to perform a cohort study of 21, births and 21, newborns from the period January 1 st to August 31 st The birth registry, which has been described in detail elsewhere [ 15 ], systematically and prospectively collects information on sociodemographic and basic obstetric indicators, as well as information on delivery modes and pregnancy outcomes.
The obstetric department receives patients from the local uptake area Moshi town in addition to referrals from a larger geographical area. CS is almost exclusively performed at hospitals in Tanzania [ 10 ], and most CS deliveries for women living in urban Moshi Moshi District Council are carried out at the facility. The site of the present study a tertiary birth centre is thus not a population-representative sample, as many women deliver at lower level facilities in the area or Looking for women in Bergsjo home.
There is potential selection towards financially better off women due to the cost-sharing policy gradually introduced for maternity services at KCMC from onwards. In comparison, The national health policy provides exemptions for the poor, but these are incompletely implemented. The Ten-Group Classification System for CS deliveries provides a standardised framework for monitoring of obstetric practice for individual institutions.
The classification is meant both for application to existing birth data, and for use as a prospective tool to identify at-risk groups. Using this standardised classification it is easy to identify which groups are the primary contributors to the overall CS rate, as well as determine CS rates and pregnancy outcomes within the different obstetric groups. CS rates in each group and contributions to overall rate can be compared across different facilities and between different levels of facilities. It has been applied internationally in high-resource settings among equivalent sub-populations [ 141920 ].
We classified women into ten mutually exclusive groups based on four obstetric characteristics: obstetric history, gestational age, category of pregnancy and course of pregnancy [ 14 ]. The essential information needed to apply the Ten-Group Classification System was available in the registry. We considered elective CS proxy for CS before labour, reflecting the practice at the facility.
Gestational age was calculated according to the last menstrual period LMP registered on the antenatal card. We categorized the main admission diagnosis recorded among women delivered by CS. For formally-referred birthing women, this was the referral diagnosis, whilst for self-referred women the receiving midwife noted the main reason for arrival.
Data on haemorrhage by clinical estimation were available from onwards. Due to the high prevalence of anaemia among pregnant women in the area, we chose a cut-off of mL as a clinically relevant level of obstetric haemorrhage [ 22 ]. The final sample included 20, births and 21, Looking for women in Bergsjo with complete information to enable classification using the Ten-Group Classification System.
Women were categorized as formally-referred when they were referred by qualified health personnel from other hospitals or health facilities such as health centres or dispensaries. The criteria for referral of women for hospital delivery from other health facilities in Tanzania can be found in Table 1. Women who came directly to KCMC, bypassing referring facilities, were categorized as self-referred birthing women. The hospital charges these women an extra registration fee. These women were categorized as self-referred if not referred for other medical or obstetric reasons.
Self-referred birthing women thus constituted a case mix of women with a wish to deliver in the facility and able to paywomen directly seeking emergency assistance for obstetric complications bypassing referral facilities for whatever reason and women recommended for delivery at KCMC due to uterine scar s but without other obstetric complications.
The hospital provides emergency transport for referrals between the regional birth centre Mawenzi and KCMC. From other facilities, transport was not regularly available. There were no community-based referral systems in place during the period. Missing referral status applied to 9. Demographic and obstetric characteristics and pregnancy outcomes for the missing cases were near identical to the total sample average data not shown.
Approval datereg. We considered ificance level p-value below 0. Table 2 presents demographic, medical and outcome characteristics for the final sample of 20, women and 21, newborns. Multiple gestations comprised 2. Demographic characteristics showed that the proportion of teenage mothers years was higher among formally-referred than self-referred birthing women Formally-referred women were more frequently rural residents and had lower educational attainments than self-referred women Table 2.
A history of FGM, a Looking for women in Bergsjo of serious maternal morbidity and unknown HIV status were also more prevalent among formally-referred women. As expected, formally-referred women had a higher rate of adverse outcomes such as low birth weight babies, maternal death, neonatal death, low Apgar score and transfer to the neonatal ward Table 2.
For other variables, there were no apparent major differences in characteristics according to referral status. This does not reflect the true facility-based MMR, as deaths in early pregnancy, in other departments or postpartum were not routinely recorded in the registry. Only deaths occurring in the facility were included in the registry. In the final sample, 6, women were delivered by CS; a facility-based CS rate of CS rates rose from Table 3 presents CS rates in the ten groups, sizes of the groups and their relative contributions to the overall rate for all births and by referral status.
Table 4 presents the main admission diagnoses by referral status for the 6, CS deliveries, as recorded in the registry. In formally-referred birthing women these were followed by "cephalo-pelvic disproportion" and "poor progress," whilst in self-referred birthing women, these were followed by "poor progress" and "foetal distress.
Table 5 presents the effect of referral status on cOR and adjusted odds ratio aOR for six maternal and neonatal outcomes after CS. Prolonged postpartum stay was associated with formally-referred status cOR 1. Analysis of neonatal outcomes after CS did not find any association between formal referral and neonatal death aOR 1. Both low Apgar score aOR 1. Maternal age was not associated with the outcomes by univariate analysis and was not included as an adjusting factor.
The absolute of cases per group is small, and data must be interpreted with caution. Obstetric haemorrhage occurred in one out of ten preterm CS deliveries group 10and was also prevalent in other obstetric high-risk groups groups Among formally-referred CS, low Apgar score was prevalent in groups 6 and 7 breech and group 10 preterm. Among self-referred CS, low Apgar score was most prevalent in group 10 preterm. Transfer to the neonatal ward occurred in one out of four formally-referred births, compared with one out of five self-referred births.
Both formally-referred and self-referred births in group 5 scar had low frequencies of obstetric haemorrhage, neonatal death and low Apgar score. Due to the gradual introduction of cost-sharing from during the period under studywe compared from before and after January 1st There was no difference in the proportion of formally-referred birthing women between the time periods Formally-referred women were ificantly younger, with a lower level of education and a higher proportion of rural residents in the second time period compared with the first.
Self-referred women on the contrary were ificantly older, had better educational attainments and a lower proportion of rural residents in the second time period. In both groups the proportion with four or more antenatal visits decreased ificantly between the first time period and the second. The overall CS rate among formally-referred birthing women fell from The main reasons for referral were the same for the two time periods.
For CS births, only neonatal death showed a crude association with the time period, with an increase of overall neonatal deaths from 0. Adding time period as an explanatory variable in the regression models did not impact on the adjusted estimates.Looking for women in Bergsjo
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Caesarean section among referred and self-referred birthing women: a cohort study from a tertiary hospital, northeastern Tanzania