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Monitoring of maternal mortality levels in sub-Saharan Africa (SSA) to assess the achievements of safe motherhood programmes and for MDG-5 has been made difficult because of the lack of precise estimates of the maternal mortality ratio (MMR). Projections based on the slow rate of decline of the MMR indicate that MDG-5 may not be reached before the end of this century in this region. Measurements done using demographical and health surveys, statistical modelling and censuses are imprecise and do not allow trends in individual countries to be established. SSA countries should be encouraged to measure mortality levels from their own resources, using methods that produce precise estimates such as population-based surveys. Establishment of the trends will lead to country-specific program targets. The less frequent but more precise measurements can be afforded by SSA countries, as a case study from Zimbabwe shows. [ABSTRACT FROM AUTHOR]

Objective To compare a five-visit antenatal care (ANC) model with specified goals with the standard model in a rural area in Zimbabwe. Design Cluster randomised controlled trial with the clinic as the randomisation unit. Setting Primary care setting in a developing country where care was provided by nurse-midwives. Population Women booking for ANC in the clinics were eligible. Main outcome measures Number of antenatal visits, antepartum and intrapartum referrals, utilization of health centre for delivery and perinatal outcomes. Methods Twenty-three rural health centres were stratified prior to random allocation to the new ( n= 11) or standard ( n= 12) model of care. Results We recruited 13 517 women (new, n= 6897 and standard, n= 6620) in the study, and 78% (10 572) of their pregnancy records were retrieved. There was no difference in median maternal age, parity and gestational age at booking between women in the standard model and those in the new model. The median number of visits was four for both models. The proportion of women with five or less visits was 77% in the new and 69% in the standard model (OR 1.5; 95% CI 1.08–2.2). The likelihood of haemoglobin testing was higher in the new model (OR 2.4; 95% CI 1.0–5.7) but unchanged for syphilis testing. There were fewer intrapartum transfers (5.4 versus 7.9% [OR 0.66; 95% CI 0.44–0.98]) in the new model but no difference in antepartum or postpartum transfers. There was no difference in rates of preterm delivery or low birthweight. The perinatal mortality was 25/1000 in standard model and 28/1000 in new model. Conclusion In Gutu district, a focused five-visit schedule did not change the number of contacts but was more effective as expressed by increased adherence to procedures and better use of institutional health care. [ABSTRACT FROM AUTHOR]

We conducted a population-based cohort study to determine the prevalence of antenatal and intra-partum referrals, compliance with advice and perinatal outcomes in referred pregnant women in Gutu district, Zimbabwe. The cohort was composed of 10,572 women who received antenatal care in 23 rural health centres (RHC) in Gutu district between January 1995 and June 1998. Pregnancy records of women with antenatal or intra-partum referral were analysed for indication, compliance and perinatal outcomes. Using women who had no antenatal referral or those who complied as referents, the association of referral with perinatal outcome was expressed as relative risk (RR) with 95% confidence intervals (CI). A total of 30% of women (3,094/10,572) had an antenatal referral. Among women attending RHC in labour, 13% (694/5,338) were referred intra-partum. Nulliparous and women younger than 20 years were more likely to be referred. Nurse – midwives' compliance with referral recommendations was low as 59% women with historical risk factors and 52% with raised blood pressure (>140/90 mmHg) were not referred. Women complied with referral advice except when indication was high parity. Women with antenatal referral were more likely to have hospital delivery, 70% vs 18% ( p [ABSTRACT FROM AUTHOR]

To determine the utilization of maternal health care services and pregnancy outcomes for women with a history of complications in previous pregnancy, we analysed the pregnancy records of multiparous women (parity ≥1) who booked and completed follow-up in Gutu district, Zimbabwe between January 1995 and June 1998. Women with previous uncomplicated pregnancies (n = 6140) were classified as low risk, whereas those with complications of previous pregnancy (n = 1077) were classified high risk. At enrolment, there was no difference in maternal age and parity between low- and high-risk women. A higher proportion of high-risk women had more than five antenatal visits (32% versus 21%; P<0.001) and gave birth in hospital (47% versus 18%; P<0.001). The risk of antenatal (relative risk [RR] 1.57; 95% confidence interval [CI] 1.32–1.88), labour/delivery (RR 1.98; 95% CI 1.75–2.25) and neonatal (RR 1.83; 95% CI 1.44–2.34) complications was elevated in high-risk women. There was increased risk for perinatal death in high-risk women, but this did not reach statistical significance (RR 1.56; 95% CI 0.98–2.49). The recurrence ratio for most complications was low and the sensitivity of historical risk markers in predicting women likely to develop further complicated pregnancies was only 23%. Most women with previous pregnancy complications can safely give birth in the rural health centre. We concluded that high-risk women had an elevated risk of complications in the index pregnancy and that better utilization of maternal health care, especially for delivery, reduced adverse perinatal outcomes. [ABSTRACT FROM AUTHOR]

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Antenatal care (ANC) attempts to screen and provide surveillance and treatment to individuals according to the level of need. We assessed the value of antenatal risk allocation made at the first visit in identifying women who will experience pregnancy complications in a rural area in Zimbabwe. As part of an ANC trial women were allocated into low- and high-risk categories based on medical, demographic and obstetric history. All highrisk women were recommended hospital delivery. This evaluation is based on 5223 women who received traditional care from nurse-midwives in 12 rural health centres, of whom 2890 (55%) were classified as high risk by the traditional risk markers, including 1618 nulliparous women. Complications occurred in 924 (17·7%) women 577 (62·4%) of whom had risk markers identified at booking. Twenty per cent (577/2890) of women classified as high risk developed complications. There was a high recurrence of complications, such as hypertensive disorders, operative delivery and preterm delivery. Nulliparity was a risk for low birth weight, operative delivery and hypertensive disorders, whereas grandmultiparity (≥6) was a risk for hypertension in pregnancy. Young age (≤16 years) was)a risk factor for low birth weight and perinatal death. Age above 35 years was not an independent risk factor. The traditional risk allocation system, with a likelihood ratio of 1·16, was not effective in identifying women at risk of pregnancy complications and resulted in too large a risk group for referral. [ABSTRACT FROM AUTHOR]