BackgroundMaternal death reviews and obstetric audits identify causes and circumstances related to occurrence of a maternal death or serious complication and inform improvements in quality of care. Given Nigeria’s high maternal mortality, the lessons learned from past experiences can provide a good evidence base for informed decision making. We aimed to synthesise findings from maternal death reviews and other obstetric audits conducted in Nigeria through a systematic review, seeking to identify common barriers and enabling factors related to the provision of emergency obstetric care.MethodsWe searched for maternal death reviews and obstetric care audits reported in the published literature from 2000–2014. A ‘best-fit’ framework approach was used to extract data using a structured data extraction form. The articles that met the inclusion criteria were assessed using a nine point quality score.ResultsOf the 1,841 abstracts and titles at initial screening, 329 full text articles were reviewed and 43 papers fulfilled the inclusion criteria. Four types of barriers were reported related to: transport and referral; health workers; availability of services; and organisational factors. Three elements stand out in Nigeria as contributing to maternal mortality: delays in Caesarean section, unavailability of magnesium sulphate and lack of safe blood transfusion services.ConclusionsObstetric care reviews and audits are useful activities to undertake and should be promoted by improving the processes used to conduct them, as well as extending their implementation to rural and basic level health facilities and to the community. Urgent areas for quality improvement in obstetric care, even in tertiary and teaching hospitals should focus on organisational factors to reduce delays in conducting Caesarean section and making blood and magnesium sulphate available for all who need these interventions.

BackgroundWomen’s delays in reaching emergency obstetric care (EmOC) facilities contribute to high maternal and perinatal mortality and morbidity in low-income countries, yet few studies have quantified travel times to EmOC and examined delays systematically. We defined a delay as the difference between a woman’s travel time to EmOC and the optimal travel time under the best case scenario. The objectives were to model travel times to EmOC and identify factors explaining delays. i.e., the difference between empirical and modelled travel times.MethodsA cost-distance approach in a raster-based geographic information system (GIS) was used for modelling travel times. Empirical data were obtained during a cross-sectional survey among women admitted in a life-threatening condition to the maternity ward of Herat Regional Hospital in Afghanistan from 2007 to 2008. Multivariable linear regression was used to identify the determinants of the log of delay.ResultsAmongst 402 women, 82 (20%) had no delay. The median modelled travel time, reported travel time, and delay were 1.0 hour [Q1-Q3: 0.6, 2.2], 3.6 hours [Q1-Q3: 1.0, 12.0], and 2.0 hours [Q1-Q3: 0.1, 9.2], respectively. The adjusted ratio (AR) of a delay of the “one-referral” group to the “self-referral” group was 4.9 [95% confidence interval (CI): 3.8-6.3]. Difficulties obtaining transportation explained some delay [AR 2.1 compared to “no difficulty”; 95% CI: 1.5-3.1]. A husband’s very large social network (> = 5 people) doubled a delay [95% CI: 1.1-3.7] compared to a moderate (3-4 people) network. Women with severe infections had a delay 2.6 times longer than those with postpartum haemorrhage (PPH) [95% CI: 1.4-4.9].ConclusionsDelays were mostly explained by the number of health facilities visited. A husband’s large social network contributed to a delay. A complication with dramatic symptoms (e.g. PPH) shortened a delay while complications with less-alarming symptoms (e.g. severe infection) prolonged it. In-depth investigations are needed to clarify whether time is spent appropriately at lower-level facilities. Community members need to be sensitised to the signs and symptoms of obstetric complications and the urgency associated with them. Health-enhancing behaviours such as birth plans should be promoted in communities.

BackgroundTraining health providers is an important strategy to improve health. We conducted a cluster-randomised two-arm trial in Tanzania to assess the effect of a 1-day competency-based training ‘Helping Mothers Survive Bleeding after Birth (HMS BAB)’ followed by eight weekly drills on postpartum haemorrhage (PPH)-related morbidity and mortality.MethodsTwenty districts in four purposefully selected regions in Tanzania included 61 facilities. The districts were randomly allocated using matched pairs to ensure similarity in terms of district health services in intervention and comparison districts. In the 10 intervention districts 331 health providers received the HMS BAB training. The other half continued with standard practices. We used the WHO’s near miss tool to collect information on severe morbidity (near misses) of all women admitted to study facilities. We performed interrupted time series analysis to estimate differences in the change of near miss per delivery rate and case fatality rates. We also assessed implementation of evidence-based preventive and basic management practices for PPH as secondary outcomes.ResultsWe included 120 533 facility deliveries, 6503 near misses and 202 maternal deaths in study districts during study period (November 2014 to January 2017). A significant reduction of PPH near misses was found among women who suffered PPH in the intervention district compared with comparison districts (difference-in-differences of slopes −5.3, 95% CI −7.8 to −2.7, p<0.001) from a baseline PPH-related near miss rate of 71% (95% CI 60% to 80%). There was a significant decrease in the long-term PPH near miss case fatality (difference-in-differences of slopes −4 to 0) (95% CI −6.5 to −1.5, p<0.01) in intervention compared with the comparison districts. The intervention had a positive effect on the proportion of PPH cases treated with intravenous oxytocin (difference-in-differences of slopes 5.2, 95% CI 1.4 to 8.9) (p <0.01).ConclusionThe positive effect of the training intervention on PPH morbidity and case fatality suggests that the training addresses important deficits in knowledge and skills.Trial registration numberPACTR201604001582128.

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