Failures in the emergency obstetric and neonatal care referral chain lead to high rates of intrapartum stillbirth in southwestern Uganda

: 1.033_WOM Failures in the emergency obstetric and neonatal care referral chain lead to high rates of intrapartum stillbirth in


Methods:
A cross-sectional household study was conducted in tehsil Kharian of district Gujrat. Data was collected using an interview based questionnaire from women who had a live birth within last two months (n¼360). The D&A scale was based on standard Maternal and Child Health Integrated Programme indicators developed by USAID. This identifies where D&A has occurred during childbirth, (objective D&A), even when women don't report that they experienced D&A (subjective D&A). Multiple logistic regression was used to examine the determinants of reported D&A.
Findings: Almost objective D&A occurred during childbirth for almost all women (99.7%). However, only 27.2% reported the subjective experience of D&A. The most common objective D&A was violation of women's right to be informed and make her own choices (97.5%), followed by abandonment of care (72.5%) and non-confidential care (58.6%). The main determinant of subjective D&A was facility based childbirth (OR¼ 13.49; 10.1-100.16) and lower socio economic strata (OR¼ 2.89;). The risk of subjective D&A in public health facilities was twice that in private health facilities. Women who reported subjective D&A were more likely to opt for changing the place of childbirth for next time (OR ¼ 4.37, 95% CI¼ 2.41-7.90).
Interpretation: D&A during childbirth is highly prevalent, although under-recognized by women in Pakistan. High prevalence of subjective D&A at facilities, and particularly at public facilities, may be a reason for underutilization of this sector for childbirth. Maternal health policies in Pakistan need to be revised based on the charter of respectful maternity care.
Source of Funding: None. Background: Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) services are an essential component of maternal and child health care. When failures or inadequacies exist in CEmONC systems, poor outcomes such as high maternal mortality and intrapartum stillbirth rates persist. An estimated 40,000 stillbirths occur in Uganda per year. The Saving Mothers Giving Life initiative (SMGL) has implemented a surveillance system known as Birth Weight and Age-at-death Boxes for Intervention and Evaluation System (BABIES) in several Ugandan districts. We assessed intrapartum stillbirth of normal weight babies in Kibaale District using the BABIES methodology.
Methods: Trends in birthweight proportionate and birthweight specific mortality were examined from 2012-2015 at all CEmONC capable facilities in Kibaale. We conducted case-specific review of all intrapartum stillbirth cases at two facilities. Key staff were also interviewed at these locations.

Findings:
The largest proportion of fetal deaths in CEmONC capable facilities occurred during the intrapartum period. Observed birthweight specific intrapartum stillbirth rates of for infants weighing greater than 2500grams during 2012-2015 were 25.7, 23.4, 21.2, 20.9 per thousand, respectively. Referral status was significantly associated with intrapartum stillbirth (p ¼< 0.0001). Kagadi Hospital (the district referral center), and St. Ambrose Charity Health Centre were identified as contributing over 75% of all deaths with facility specific rates of 22.2 per thousand and 74.2 per thousand in 2015 respectively. Systematic review of records for individual intrapartum stillbirth cases at both facilities in 2015 revealed challenges with the CEmONC referral chain. 62.5% of intrapartum stillbirth cases at St. Ambrose Health Centre were referrals from Kagadi Hospital, and 86.7% of the time the patient was admitted with an undetectable fetal heart rate. Major human resource strains and poor intrapartum monitoring at Kagadi Hospital were identified as reasons for late referrals to the lower level private facility and poor outcomes at both health facilities.
Interpretation: These findings suggest a need for restructuring of the CEmONC referral chain in the greater Kibaale region of Uganda, and programs to increase quality of care during delivery.
Source of Funding: University of Notre Dame: Eck Institute for Global Heath.