Determinants of maternal length of stay following childbirth in a rural health facility in Eritrea

Childbirth is a physiologic process considered spontaneous and safe when it takes place in health facilities, but complications can arise regardless of the place of delivery. Therefore, it’s important to for mothers to stay in health facilities where there is a skilled birth attendant who can identify and respond to any complications. The WHO also advocates for an adequate postpartum stay for the timely detection of maternal and neonatal complications.

In this study, nearly one-third of mothers had inadequate LOS following vaginal birth. The magnitude of inadequate LOS remains a challenge in SSA, with a substantial proportion of mothers staying in health facilities for less than 1 day, Tanzania (65.7%) [6], Ethiopia (65.2%) [12], Ghana (35%), and Swaziland (18.5%) [9]. More importantly, a study evaluating the provision of postpartum care in 33 SSA countries noted substantial variation between countries, with the median country percentage being 71.7% and ranging from 26.6% in Swaziland to 94.4% in Burkina Faso. Nonetheless, the investigators reported that less than 50% of mothers reported the provision of pre-discharge check-ups following childbirth in nearly one-fourth of the SSA countries included in the study [26].

In Africa, discharge within 24 h following vaginal facility delivery is considered an institutional norm and a societal expectation, except in the presence of a complication [6]. A study in Tanzania found that although the time of discharge was decided by healthcare providers, women were happy to leave before 24 h, either due to a longing to be home or due to some facility-related discontentment [6]. Such factors may perhaps be attributable to this setting as well, since Nakfa Hospital is a remote health facility with limited infrastructure. No doubt, inadequate LOS can have detrimental effects on both maternal and neonatal health [19, 20]. Appropriate postpartum LOS provides enough time for the assessment of the mother and newborn. It also provides us with critical opportunities for counseling about exclusive breastfeeding and to discuss the mother’s childbirth experience during their hospital stay. Therefore; efforts to improve adherence to the WHO recommendation on the minimum length of stay after childbirth, in addition to improving the facility environment to enable a longer stay, should be prioritized in this setting.

Unsurprisingly, CD resulted in a longer median LOS as compared to SVD in this population. Reports generally suggest a longer LOS following CD [21, 26]. Women who have caesarean deliveries, irrespective of demographic and obstetric characteristics, have a higher risk of maternal morbidity compared to VDs [27, 28], hence a longer LOS. Furthermore, the median LOS was 6 days in this setting. Prior Reports have documented that LOS following CD has large variability (2.5–9.3 days) across different contexts [10]. Lower median LOS following CD has been reported in Sudan [29], Australia [30], and the US [25, 31]. On the other hand, comparable LOS in mothers who delivered via CD has been reported in India [21], Malawi, and Ghana [9]. When compared with elective CD, Emergency CD was associated with a longer LOS. A prior study in Sudan reported a relatable finding [25]. This can perhaps be explained by the fact that emergency CD is associated with more maternal complications and, hence, longer hospitalization [31]. Thus, early detection of high-risk mothers through the provision of high-quality antenatal care and follow-up should be worked upon.

Interestingly, deliveries attended by a physician were unlikely to result in an inadequate stay as compared to midwives and Associate nurse staff. This finding concurs with prior literature. A study in Nepal concluded similar findings: delivery attended by an Associate nurse staff was associated with a shorter length of stay, as compared with delivery attended by a physician and a nurse, even after adjusting for complications and other factors (IRR = 0.86, 95% CI 0.75 to 0.98) [32]. No doubt, equipped with a higher extent of academic and clinical training, doctors would have better rates of adherence to the standard LOS and a superior capacity for identifying both maternal and neonatal complications. Indeed; a study evaluating the competence of healthcare professionals in diagnosing and managing obstetric complications identified that median scores differed significantly between different levels of health professionals, 11 (IQR: 7–14) points for medical doctors vs. 8 (IQR: 6–10) points for nurses and midwives (p = 0.0002) [33]. More importantly, suboptimal provision of postpartum care for women giving birth in health facilities in 33 sub-Saharan African countries was found to be associated with the level of health professionals. According to this report, as compared to physicians, midwives and skilled birth attendants had a lower provision of postpartum check-ups (AOR = 0.74, 95% CI: 0.69–0.78 and 0.14, 95% CI: 0.12–0.15, respectively) [26]. All things considered, this factor may capture larger issues of insufficient staffing, poor training, and low adherence to guidelines in this setting. Moreover; Nurses or midwives usually attend less risky births and consult on complicated births with physicians that require an indicated extension of stay. Another explanation is that dimensions related to the health system and women or family dimensions that might be drivers for inappropriately short stays are more likely to have an effect on these less risky childbirths.

The present study found maternal complications were an independent determinant of longer LOS following VD. The finding is consistent with Prior literature reports [29, 34]. The provision of post-partum care is essential for mothers following childbirth, even more so for mothers who experience complications during labor. Therefore, it’s not surprising for mothers who incur complications to stay longer in a hospital where postnatal care is available. Indeed, length of stay has been observed to improve the utilization of postpartum care [21]. Moreover, mothers who delivered neonates with a 5-minute Apgar score less than 4 had a significantly longer median LOS. The results of our study collaborate with existing evidence. Indeed, previous investigators have noted that neonatal complications result in a longer duration of stay [29]. The Apgar score is a simple and replicable method to quickly and summarily assess the health of newborn children immediately after birth [35]. Generally, the Apgar score is an indicator of how well the neonate adapts to the transition from life in utero to the environment. No wonder neonates with lower 5-minute Apgar scores need better postnatal care, for example, admission to the neonatal ICU, which requires mothers to stay an additional day to breastfeed their babies.

Concerning time of delivery, both delivery hour and delivery year were determinants of LOS. On the latter, mothers who delivered in the years 2020 and 2021 had higher LOS as compared to 2022. The impact of COVID-19 on healthcare systems can perhaps be invoked to explain the observed difference in LOS. Fragile health systems in developing countries faced organizational and resource constraints when confronted with the Covid 19 pandemic. A systematic review of 81 studies across 20 countries reported a median 37% reduction in overall healthcare utilization and a median 42% reduction in health facility visits [36]. In contrast, in this study, the proportion of VD remained fairly stable throughout the study period [706 (35.7%) in 2020, 678 (34.3%) in 2021, and 591 (29.9%) in 2022]. Despite the stable proportion of VD across the years, mothers that delivered in the years 2020 and 2021 had longer median LOS and higher incidence rate ratios of LOS. In Eritrea, lockdown was instituted in early 2020 and lasted all the way to the latter half of 2021. It is likely that a lack of transportation coupled with poor accessibility infrastructure resulted in postpartum mothers staying in the facility longer, even more so during the lockdown of 2020 and 2021. Moreover, this study uncovered that mothers who delivered between 22:00 and 8:00 had a significantly shorter stay as compared to those who delivered between 8:00–21:00. Similarly, Ikeda et al. noted that mothers who gave birth between 11:00 and 02:00 were more likely to stay longer (11:00–19:00: IRR = 1.11, 95%CI 1.01 to 1.22, 20:00–02:00: IRR = 1.15, 95%CI 1.02 to 1.30), as compared with those who gave birth between 03:00 and 10:00 [32]. Nakfa subzone is located in mountainous topography with poor access, road infrastructure, and transportation options. In this setting, going home after dark can be difficult for postpartum mothers given the lack of transportation. After it gets dark, going home with a postnatal mother and child without transportation can be difficult in such settings. In the open literature, evidence suggests such factors can be influential in similar settings [32].

Lastly, assisted VDs were infrequent in this study, with only 9 (0.5%) of VDs. In contrast, in a retrospective review of records involving 4396 mothers from nine sub-Saharan African countries, the proportion of assisted VD was 18% [37]. Similarly, a study conducted in Tanzania reported a higher rate of assisted VD (3.9%) [38]. This low rate of instrumental VD could be attributed to incorrect documentation, as investigators in the above study in Tanzania noticed that instrumental VD were sometimes recorded by midwives as spontaneous VDs. Another reason is that healthcare professionals in resource-limited settings are often less experienced with instrumental VD techniques [37].