title: Effect of maternal death reviews and training on maternal mortality among cesarean delivery: post-hoc analysis of a cluster-randomized controlled trial.
abstract: OBJECTIVE
  To explore the differential effect of a multifaceted intervention on hospital-based maternal mortality between patients with cesarean and vaginal delivery in low-resource settings.
  
  
  METHODS
  We reanalyzed the data from a major cluster-randomized controlled trial, QUARITE (Quality of care, Risk management and technology in obstetrics). These subgroup analyses were not pre-specified and were treated as exploratory. The intervention consisted of an initial interactive workshop and quarterly educational clinically oriented and evidence-based outreach visits focused on maternal death reviews (MDR) and best practices implementation. The trial originally recruited 191,167 patients who delivered in each of the 46 participating hospitals in Mali and Senegal, between 2007 and 2011. The primary endpoint was hospital-based maternal mortality. Subgroup-specific Odds Ratios (ORs) of maternal mortality were computed and tested for differential intervention effect using generalized linear mixed model between two subgroups (cesarean: 40,975; and vaginal delivery: 150,192).
  
  
  RESULTS
  The test for homogeneity of intervention effects on hospital-based maternal mortality among the two delivery mode subgroups was statistically significant (p-value: 0.0201). Compared to the control, the adjusted OR of maternal mortality was 0.71 (95% CI: 0.58-0.82, p=0.0034) among women with cesarean delivery. The intervention had no significant effect among women with vaginal delivery (adjusted OR 0.87, 95% CI 0.69-1.11, p=0.6213). This differential effect was particularly marked for district hospitals.
  
  
  CONCLUSIONS
  Maternal deaths reviews and on-site training on emergency obstetric care may be more effective in reducing maternal mortality among high-risk women who need a cesarean section than among low-risk women with vaginal delivery.
authors.affiliation: Health Sciences Research Institute (IRSS), Ouagadougou, Burkina Faso; Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France. Electronic address: zongoaugustin@yahoo.fr.
authors.forename: Augustin
authors.initials: A
authors.lastname: Zongo
authors.affiliation: Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France; Hospital Research Centre, University of Montreal (CRCHUM), Canada.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Dumont
authors.affiliation: Hospital Research Centre, University of Montreal (CRCHUM), Canada.
authors.forename: Pierre
authors.initials: P
authors.lastname: Fournier
authors.affiliation: URFOSAME, Referral Health Centre of Commune V, Bamako, Mali.
authors.forename: Mamadou
authors.initials: M
authors.lastname: Traore
authors.affiliation: Health Sciences Research Institute (IRSS), Ouagadougou, Burkina Faso.
authors.forename: Séni
authors.initials: S
authors.lastname: Kouanda
authors.affiliation: University of Ouagadougou, UFR-SDS, Ouagadougou, Burkina Faso.
authors.forename: Blaise
authors.initials: B
authors.lastname: Sondo
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000401:mortality*; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D008302:Mali / Q000453:epidemiology; D008428:Maternal Mortality; D008485:Medical Audit; D011247:Pregnancy; D058996:Quality Improvement; D012675:Senegal / Q000453:epidemiology
keywords: Cesarean delivery; Emergency obstetric care; Maternal mortality; Quality improvement; Sub-Saharan Africa