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 thenineprovinces and two from thelargest 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. Keywords: Standard primipara, Quality of care, Obstetric process indicators, Obstetric outcome indicators, the perinatal mortality rate Background risk of dying during pregnancy in low-resource countries The previous millennium development goal (MDG) is the new target in the developed sustainable develop- number 5 targeted to reduce maternal deaths by 75% by ment goal (SDG) number 3, targeting to reduce the glo- the year 2015. This unrealistic target was not achieved bal maternal mortality ratio to less than 70 per 100,000 because there is still a great need for unrestricted access live births by 2030. to high-quality emergency obstetric care to reduce the The lifetime risk of dying due to pregnancy-related high risk of dying in pregnancy which is still prevalent in complications in Sub-Saharan Africa is 1 in 39 compared the low-resource countries . Thus reducing this great to 1 in 4600 in the United Kingdom and 1 in 3800 in high-income countries in general . To improve maternity services, there is need to moni- * Correspondence: firstname.lastname@example.org tor and improve the quality of care women receive in Department of Obstetrics and Gynaecology, University of Zimbabwe, different obstetric units. One limitation though is that College of Health Sciences, P.O. Box A178, Avondale, Harare, Zimbabwe Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Guzha et al. BMC Pregnancy and Childbirth (2018) 18:205 Page 2 of 6 there is no universally agreed definition of quality of care healthcare facilities and also from homes and villages. A (QoC). This explains the variation in obstetric outcomes data entry template was designed in Microsoft Access like caesarean section, instrumental delivery and induc- and used for data capture. Alfirevic et al. defined the tion of labour rates among different health institutions standard primipara as a woman in her first pregnancy, within the same setting . In most countries, there is a with a singleton fetus in cephalic presentation, with disparity of care and outcomes among different obstetric spontaneous onset of labour between 37 + 0 weeks and units . For this to be corrected there is need to come 42 + 0 weeks, with no antenatal complications or previ- up with a tool that can be used to compare the quality ous hospital admission lasting more than 24 h . This of care between the different institutions. The tool was the definition of the standard primipara used in this should be able to control for confounding factors like study. Data from all the districts in the main study were difference in patient characteristics and disease patterns. used to extract records for women who met the defin- In Zimbabwe, like in most countries, the difference in ition of the standard primipara; and subsequent data the quality of care among the different geographical analyses were performed in Stata Version 9.0 (StataCorp areas is difficult to determine because of heterogeneous LP, College Station, TX). The standard primiparae were population characteristics and the difference in preva- then used to compare maternal and perinatal process lence of complications in those areas. The concept of and outcome indicators between rural and urban, across the standard primipara was introduced as a basis of urban and across rural districts. Pearson chi-squared test inter-unit comparison in evaluating the quality of obstet- was used to determine the association between the ric services to minimise the risks of bias . Alfirevic categorical variables. The quality of obstetric care was et al. used this concept in comparing the impact of de- assessed using the following indicators: livery suite guidelines on intrapartum care among differ- a) Obstetric process indicators:Booking status (at least ent health institutions . Some maternal and perinatal one antenatal visit), gestational age at booking, antenatal process and outcome indicators were then used as tools human immunodeficiency virus (HIV) screening rate, to compare the quality of obstetric care among the dif- and initial place of onset of labour, utilisation of mater- ferent geographical districts in Zimbabwe [6, 7]. nity waiting shelters in the rural districts, institutional The availability of comprehensive obstetric care in delivery rate, intrapartum complication detection rate, various settings depends on local conditions and the re- and referral in labour rate, operative vaginal delivery sources available. There is no available data looking at rate, caesarean section rate and the postpartum referral the quality of obstetric care among the different districts rate. in the different Provinces of Zimbabwe. This study was b) Obstetric outcome indicators:PNMR. done to identify the districts with poor quality of obstet- ric care. This data is important to improve maternity Results services in poorly performing districts to match those of In the main study, a total of 45,240 births were recruited areas that had better performance. from the 11 districts and 10,947 women met the defin- ition of standard primipara. Methods As shown in Table 1 below, the median (Q1; Q3) age Zimbabwe is divided into 10 administrative Provinces, of the women was 20 (18; 22) years. which are divided into 59 Districts. Harare, the biggest As shown in Table 2 below, the vast majority of the Province has urban districts only unlike all the other standard primiparas booked their pregnancies (94.1%) Provinces which are comprised of urban and rural dis- and the median (Q1; Q3) gestation at booking was 24 tricts. The Zimbabwe Maternal and Perinatal Mortality (20; 28) weeks. Less than half of them (42.4%) were Study (ZMPMS) was a population-based descriptive and screened for HIV in the antenatal period. The institu- cross-sectional study of deaths of women in pregnancy tional delivery rate was high at 87.8, and 8.8% of them and perinatal deaths in Zimbabwe. The study was done were referred to higher levels of care for intrapartum to estimate the maternal mortality ratio (MMR) and the complications. The caesarean section and vacuum deliv- perinatal mortality rate (PNMR) in Zimbabwe . Data ery rates were low at 4.1 and 1.4% respectively. Com- were collected from the 1st of May 2007 to the 30th pared to the rest of the women in the 11 districts, the April 2008. Cluster sampling was done with the 10 prov- standard primiparas had lower maternal mortality ratios inces as clusters and 11 districts were randomly selected (92/100000 live births vs 698/100000 live births, p < with one from each of the 9 provinces and 2 from 0.001). The perinatal mortality rates were also lower in Harare which is the biggest province in Zimbabwe. In the standard primiparas (15.4/ 1000 total births vs 31.9/ these 11 districts, pregnancy outcomes were collected 1000 total births, p < 0.001). prospectively on all women delivering after 22 weeks As shown in the Table 3 below, in the urban to rural gestation for 11 months . Data were collected from all districts comparison, there were significant differences Guzha et al. BMC Pregnancy and Childbirth (2018) 18:205 Page 3 of 6 Table 1 Demographic characteristics of the standard primiparae, Table 3 Comparison between rural and urban districts stratified by district Process Indicators Rural Urban *p-value N = 6026 N = 4921 District/ Area Sample size Median age (years) (Q1; Q3) Booking status (%) 94.9 94.5 0.394 Rural Mean gestation at booking 22.4 25.3 < 0.001 (weeks) Bindura 837 19 (18;21) Antenatal HIV screening (%) 37.8 60.1 < 0.001 Chivi 1394 20 (18;22) Initial place of onset labour- 30.6 5.6 < 0.001 Matobo 617 19 (17;20) institutional (%) Mutoko 778 19 (18;21) Institutional deliveries (%) 80.2 97.1 < 0.001 Tsholotsho 648 18 (17;20) Intrapartum complications 7.4 18.3 < 0.001 Zvimba 1005 20 (18;22) detected (%) Urban Referrals in labour (%) 3.1 15.8 < 0.001 South Eastern district of Harare 444 23 (20;25) Caesarean section rate (%) 2.2 6.5 < 0.001 Western district of Harare 1463 21 (19;23) Vacuum delivery rate (%) 0.5 2.5 < 0.001 Kwekwe 1398 20 (18;23) Post-partum referrals (%) 0.4 1.2 < 0.001 Nkulumane 1159 21.(19;23 Outcome Indicators Mutare 1204 20 (19;23) PNMR (N/1000 births) 19 11 0.001 Area Abbreviations: HIV human immunodeficiency virus, PNMR perinatal mortality rate Rural 6026 19 (18;21) *= Analysis of process and outcome indicators between districts Urban 4921 21 (19;23) Total 10,947 20 (18; 22) process indicators: booking status, antenatal HIV screen- ing rate, and initial place of onset of labour, institutional in the following process indicators: mean gestation at delivery rate, intrapartum complications detection rate, booking, antenatal HIV screening rate, initial place of referral in labour rate, caesarean section rate, vacuum onset of labour, institutional delivery rate, intrapartum delivery rate and post-partum referral rate. There was complication detection rate, and referral in labour rate, no significant difference in the PNMR. caesarean section rate, vacuum delivery rate and As shown in Table 5 below, across the rural districts, post-partum referral rate. The urban districts had a sig- there were significant differences in the following nificantly lower PNMR. process indicators: booking status, mean gestation at As shown in Table 4 below, across the urban districts, booking, antenatal HIV screening rate, initial place of there were significant differences in the following onset of labour, institutional delivery rate, intrapartum complications detection rate, referral in labour rate and vacuum delivery rate. There was no significant difference Table 2 Obstetric indicators for the standard primiparae in the PNMR. Process Indicators Standard primipara As shown in Table 6 below, the standard primiparas N = 10,947 had significantly better obstetric and process outcome Booking status (%) 94.1 indicators than the general obstetric population. Mean gestation at booking (weeks) 23.6 Antenatal HIV screening (%) 42.4 Discussion Initial place of onset of labour-institutional (%) 19.4 Compared to the total ZMPMS population, the standard Institutional deliveries (%) 87.8 primiparas had a lower maternal mortality ratio and perinatal mortality rate (see Table 6). This confirms that Intra partum complications detected (%) 12.3 this was a low-risk group and the differences in out- Referrals in labour (%) 8.8 comes were probably due to variation in quality of ser- Caesarean section rate (%) 4.1 vice provision than patient-related factors. Vacuum delivery rate (%) 1.4 Across urban and across rural districts (see Tables 4 Post-partum referrals (%) 5.5 and 5), there were significant differences in most of the Outcome Indicators obstetric process indicators. Some of the differences across the rural or urban districts were inexplicable con- PNMR (N/1000 births) 15.4 sidering that they get similar resources from the central Abbreviations: HIV human immunodeficiency virus, PNMR perinatal mortality rate Government. There is need to investigate why this is Guzha et al. BMC Pregnancy and Childbirth (2018) 18:205 Page 4 of 6 Table 4 Comparison across urban districts Process Indicators South Eastern district of Harare Western district of Harare Kwekwe Mutare Nkulumane *p-value Booking status (%) 95.7 90.7 96.8 96.5 95.4 < 0.001 Mean gestation at booking (weeks) 23.8 26.0 23.7 24.7 26.6 0.122 Antenatal HIV screening (%) 31.0 52.5 49.5 61.6 86.6 < 0.001 Initial place of onset of labour-institutional (%) 2.7 5.6 2.2 15.2 1.3 < 0.001 Institutional deliveries (%) 98.0 96.6 97.4 98.3 96.3 0.033 Intrapartum complications detected (%) 28.4 19.5 19.6 12.5 17.0 < 0.001 Referrals in labour (%) 9.5 16.7 14.1 23.4 12.1 < 0.001 Caesarean section rate (%) 8.4 5.0 9.8 5.7 5.9 < 0.001 Vacuum delivery rate (%) 15.9 2.0 0.5 0.1 1.5 < 0.001 Post-partum referrals (%) 1.6 1.6 0.7 0.1 2.3 0.001 Outcome Indicators PNMR (N/1000 births) 7 12 14 11 9.5 0.777 Abbreviations: HIV human immunodeficiency virus, PNMR perinatal mortality rate *= Analysis of process and outcome indicators between districts happening and offer remedial action to enable standar- . Zimbabwe has adopted the World Health Organisa- dised maternity care in Zimbabwe. Surprisingly these tion (WHO) HIV guidelines which recommended that all differences did not have an impact on the PNMR. The HIV-infected pregnant women be put on anti-retroviral study was not powered to detect a difference in the treatment regardless of their CD4+ or viral load count MMR among the individual districts. . Therefore, there is need to put mechanisms in place In the rural to urban districts comparison (see Table 3), to make sure that all pregnant women are screened for the only obstetric process indicator that did not show a HIV and those infected are put on treatment to reduce significant difference was the antenatal booking status. the MMR and parents to child transmission rates of HIV. The provision of free antenatal care in the Government More standard primiparae in the urban districts had rural clinics could explain why booking rates are high in access to skilled birth attendants (SBA) (97.1% vs 80.2%, both the rural and urban districts of Zimbabwe . Des- p < 0.001) (see Table 3). The low rate of delivery by pite these high booking rates, antenatal HIV screening skilled birth attendants in the rural districts fell below rates remain low in both urban and rural districts (60.1% the target of 90% set by the WHO . Due to unavail- vs 37.8%, p < 0.001). This probably explains why a quarter ability of transport, almost 20% of women ended up de- of maternal deaths in Zimbabwe are still due to HIV/AIDS livering outside institutions. Table 5 Comparison across rural districts Outcome Indicators Bindura Chivi Kwekwe Matobo Mutare Mutoko Zvimba Tsholotsho *p-value Booking status (%) 95.3 97.3 97.6 98.0 96.1 96.8 98.1 84.0 < 0.001 Mean gestation at booking (weeks) 21.6 19.3 25.0 25.7 23.4 23.3 23.9 23.0 < 0.001 Antenatal HIV screening (%) 34.7 10.4 14.9 43.6 69.0 40.2 70.6 55.0 < 0.001 Initial place of onset of labour (%) 1.1 48.0 3.5 58.0 18.3 26.6 0.1 55.7 < 0.001 Institutional deliveries (%) 71.1 90.7 67.1 85.6 87.8 75.4 81.1 77.7 < 0.001 Intra partum complications detected (%) 4.1 4.4 6.9 10.3 2.7 16.2 3.9 9.3 < 0.001 Referrals in labour (%) 4.6 4.4 3.3 1.3 3.1 0.8 1.1 4.4 < 0.001 Caesarean section rate (%) 2.3 1.9 2.3 1.8 1.0 2.4 3.0 2.1 0.645 Vacuum delivery rate (%) 0.5 0.4 0.0 2.3 0.0 0.1 0.0 0.5 < 0.001 Post-partum referrals (%) 0.4 0.2 0.0 0.9 0.0 0.4 0.3 1.0 0.066 Outcome Indicators PNMR (N/1000 births) 24 22 18 20 31 14 22 10 0.234 Abbreviations: HIV human immunodeficiency virus, PNMR perinatal mortality rate and *= Analysis of process and outcome indicators between districts Guzha et al. BMC Pregnancy and Childbirth (2018) 18:205 Page 5 of 6 Table 6 Comparison between the standard primipara and the To the best of our knowledge, no study has been done general obstetric population in Africa utilising this tool to measure the quality of ob- Process Indicators Standard Non-Standard *p-value stetric care between institutions in one country. A pilot primipara primipara study can also be done to assess its feasibility in compar- N = 10,947 N = 34,293 ing the quality of obstetric care among different coun- Booking status (%) 94.1 76.7 < 0.001 tries in Africa. Mean gestation at booking 23.6 24.5 < 0.001 (weeks) Abbreviations AIDS: Acquired Immunodeficiency Syndrome; HIV: Human Immunodeficiency Antenatal HIV screening (%) 42.4 31.2 < 0.001 Virus; MDG: Millennium Development Goal; MMR: Maternal Mortality Ratio; Initial place of onset of labour- 19.4 10.9 < 0.001 MOHCC: Ministry of Health and Child Care; PNMR: Perinatal Mortality Rate; institutional (%) QoC: Quality of Care; SBA: Skilled Birth Attendant; SDG: Sustainable Development Goal; WHO: World Health Organization; ZMPMS: Zimbabwe Institutional deliveries (%) 87.8 62.4 < 0.001 Maternal and Perinatal Mortality Study Intra partum complications 12.3 11.7 0.091 detected (%) Acknowledgements This was a substudy of the Zimbabwe Maternal and Perinatal Mortality Study Referrals in labour (%) 8.8 5.1 < 0.001 (ZMPMS). Caesarean section rate (%) 4.1 3.8 0.157 Funding Vacuum delivery rate (%) 1.4 0.7 < 0.001 The main study, the Zimbabwe Maternal and Perinatal Mortality Study Post-partum referrals (%) 5.5 1.0 < 0.001 (ZMPMS) was funded by the United Kingdom (UK), Department for International Development (DfID). This sub-study was done utilising data Outcome Indicators from the main study. The funders of the main study had no role in the design, collection, analysis, and interpretation of data and in writing the PNMR (N/1000 births) 15.4 31.9 < 0.001 manuscript. Abbreviations: HIV human immunodeficiency virus, PNMR perinatal mortality rate Availability of data and materials *= Analysis of process and outcome indicators between districts The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. In the urban districts, the number of standard primipa- ras delivering in comprehensive emergency obstetric units Authors’ contributions BTG, TLM, BM, SPM, MC and GN designed the study; MC and GN did the and caesarean section rates meet the minimum targets set data analysis; BTG and SPM wrote the manuscript with SPM being the senior by the WHO of 15 and 5%, respectively [1, 12]. In the author. All the authors read and approved the manuscript. rural districts, the caesarean section rate of 2.2% is way Ethics approval and consent to participate below the WHO recommendation. Coupled with this, the The ZMPMS protocol was approved by the Medical Research Council of operative vaginal delivery rate of 0.5% is way below the Zimbabwe (MRCZ) (reference number MRCZ/A1368). In the main study prior 2.5% in the urban districts. The low caesarean and opera- informed written consent was given by all the subjects. tive delivery rates in the rural districts could be as a result Competing interests of lack of personnel who are trained to do the procedures The authors declare that they have no competing interests. and a reluctance to attempt vacuum deliveries in remote areas, and this could explain the higher PNMR. Although Publisher’sNote the Central Government through the Ministry of Health Springer Nature remains neutral with regard to jurisdictional claims in and Child Care (MOHCC) has started to enforce the pol- published maps and institutional affiliations. icy of deploying recently qualified doctors to the rural dis- Author details tricts, this might not have an impact in the long term Department of Obstetrics and Gynaecology, University of Zimbabwe, unless maternity waiting shelters are fully utilised to im- College of Health Sciences, P.O. Box A178, Avondale, Harare, Zimbabwe. Department of Medicine, Division of Clinical Pharmacology, University of prove the institutional delivery rates in these areas. Cape Town, K45 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa. Biomedical Research and Training Institute, Conclusions 10 Seagrave Avenue, Avondale, Harare, Zimbabwe. The study has shown that the standard primipara is a Received: 30 November 2017 Accepted: 29 May 2018 useful tool to measure the quality of obstetric care in different districts in Zimbabwe. Therefore every dis- trict should measure process and outcome indicators References 1. Paxton A, Maine D, Freedman L, Fry D, Lobis S. The evidence for emergency of the standard primipara. The MOHCC can use this obstetric care. Int J Gynaecol Obstet. 2005;88(2):181–93. PubMed Abstract | tool to monitor improvement in obstetric care and to Publisher Full Text find out the specific reasons for the discrepancy in 2. How many women and girls die in childbirth? http://www.maternityworldwide. org/the-issues. Accessed 26 Sept 2014 the different obstetric process indicators and how this 3. Faisel H, Pittrof R, El-Hosini M, Habib M, Azzam E. Using standard primipara variation in service provision can be corrected at local method to compare quality of care in Cairo and London. J Obstet Gynaecol. and national level. 2009;29(4):284–7. Guzha et al. BMC Pregnancy and Childbirth (2018) 18:205 Page 6 of 6 4. Cleary R, Beard RW, Chapple J, Colles J, Griffin M, Joffe M, Welch A. The standard primipara as a basis of inter-unit comparisons of maternity care. Br J Obstet Gynaecol. 1996;103(3):223–9. 5. Alfirevic Z, Edwards G, Platt MJ. The impact of delivery suite guidelines on intrapartum care in standard primigravida. Eur J Obstet Gynecol Reprod Biol. 2004;115(1):28–31. 6. AMDD. Program note: using UN process indicators to assess needs in emergency obstetric services: Morocco, Nicaragua and Sri Lanka. Int J Gynaecol Obstet. 2003;80(2):222–30. PubMed Abstract | Publisher Full Text 7. Gottlieb P, Lindmark G. WHO indicators for evaluation of maternal health care services, applicability in least developed countries: a case study from Eritrea. Afr J Reprod Health. 2002;6(2):13–22. 8. Munjanja SP, Nystrom L, Nyandoro M, Magwali T. Maternal and Perinatal Mortality Study. 2007. http://www.unicef.org/zimbabwe/ZMPMS_report.pdf. 9. Raatikainen K, Heiskanen N, Heinonen S. Under-attending free antenatal care is associated with adverse pregnancy outcomes. BMC Public Health. 2007;7:268. 10. HIV and infant feeding. Revised principles and recommendations. Geneva: World Health Organization; 2009. 11. Report of the Ad Hoc Committee of the Whole of the Twenty-first Special Session of the General Assembly (General Assembly document, No. A/S-21/ 5/Add.1). New York: UN; 1999. Available at http://www.un.org/popin/ unpopcom/32ndsess/gass/215a1e.pdf. 12. World Health Organization. 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