Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes.

The third stage of labor is defined as the time period between delivery of the fetus through delivery of the placenta. During a normal third stage, uterine contractions lead to separation and expulsion of the placenta from the uterus. Postpartum hemorrhage is a relatively common complication of the third stage of labor. Strategies have been studied to mitigate the risk of postpartum hemorrhage, leading to the widespread implementation of active management of the third stage of labor. Initially, active management of the third stage of labor consisted of a bundle of interventions including administration of a uterotonic agent, early cord clamping, controlled cord traction, and external uterine massage. However, the effectiveness of these interventions as a bundle has been questioned, leading to abandonment of some components in recent years. Despite this, upon review of selected international guidelines, we found that the term "active management of the third stage of labor" was still used, but recommendations for and against individual interventions were variable and not necessarily supported by current evidence. In this review, we: (1) examine the physiology of the third stage of labor, (2) present evidence related to interventions that prevent postpartum hemorrhage and promote maternal and neonatal health, (3) review current global guidelines and recommendations for practice, and (4) propose future areas of investigation. The interventions in this review include pharmacologic agents to prevent postpartum hemorrhage, cord clamping, cord milking, cord traction, cord drainage, early skin-to-skin contact, and nipple stimulation. Treatment of complications of the third stage of labor is outside of the scope of this review. We conclude that current evidence supports the use of effective pharmacologic postpartum hemorrhage prophylaxis, delayed cord clamping, early skin-to-skin contact, and controlled cord traction at delivery when feasible. The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine; oxytocin plus misoprostol; or carbetocin. After cesarean delivery, carbetocin or oxytocin as a bolus are the most effective regimens. There is inconsistent evidence regarding the use of tranexamic acid in addition to a uterotonic compared with a uterotonic alone for postpartum hemorrhage prevention after all deliveries. Because of differences in patient comorbidities, costs, and availability of resources and staff, decisions to use specific prevention strategies are dependent on patient- and system-level factors. We recommend that the term "active management of the third stage of labor" as a combined intervention no longer be used. Instead, we recommend that "third stage care" be adopted, which promotes the implementation of evidence-based interventions that incorporate practices that are safe and beneficial for both the woman and neonate.

Changes in reproductive, maternal, and child health in Haiti during the pre- and peri-COVID-19 pandemic.

Objective: To assess changes in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) in Haiti from August 2018 to September 2021, before and during the COVID-19 pandemic. Methods: A retrospective study using surveillance data from the Haitian Unique Health Information System, examining two periods: pre- and peri-COVID-19 pandemic. Health indicators at the national level in the two periods were compared using two-sample t-tests for proportions, and average absolute monthly changes were calculated using variance-weighted regression. Results: There was a statistically significant decline in the proportion of most of the indicators assessed from the pre- to the peri-COVID-19 pandemic period. However, the most affected indicators were the proportions of pregnant women with four antenatal care visits, with five antenatal care visits or more, and those who received a second dose of tetanus vaccine, which decreased by over 4 percentage points during the two periods. Likewise, the proportions of children who received diphtheria, tetanus, and pertussis (DTaP), BCG, polio, pentavalent, and rotavirus vaccines also all declined by over 8 percentage points. In contrast, pneumococcal conjugate vaccine increased by over 4 percentage points. A statistically significant decrease was also observed in the average absolute monthly changes of several reproductive and child health indicators assessed. Conclusions: The COVID-19 pandemic may have contributed to the decline observed in several RMNCAH indicators in Haiti. However, the role played by the sociopolitical crisis and control exercised by armed groups over the population in the last three years cannot be ruled out.

Scenarios of maternal mortality reduction by 2030 in the Americas: insights from its tempo.

BACKGROUND: The enduring threat of maternal mortality to health worldwide and in the Americas has been recognized in the global and regional agendas and their targets to 2030. To inform the direction and amount of effort needed to meet those targets, a set of equity-sensitive regional scenarios of maternal mortality ratio (MMR) reduction based on its tempo or speed of change from baseline year 2015 was developed. METHODS: Regional scenarios by 2030 were defined according to: i) the MMR average annual rate of reduction (AARR) needed to meet the global (70 per 100,000) or regional (30 per 100,000) targets and, ii) the horizontal (proportional) or vertical (progressive) equity criterion applied to the cross-country AARR distribution (i.e., same speed to all countries or faster for those with higher baseline MMR). MMR average and inequality gaps -absolute (AIG), and relative (RIG)- were scenario outcomes. RESULTS: At baseline, MMR was 59.2 per 100,000; AIG was 313.4 per 100,000 and RIG was 19.0 between countries with baseline MMR over twice the global target and those below the regional target. The AARR needed to meet the global and regional targets were -7.60% and -4.54%, respectively; baseline AARR was -1.55%. In the regional MMR target attainment scenario, applying horizontal equity would decrease AIG to 158.7 per 100,000 and RIG will remain invariant; applying vertical equity would decrease AIG to 130.9 per 100,000 and RIG would decrease to 13.5 by 2030. CONCLUSION: The dual challenge of reducing maternal mortality and abating its inequalities will demand hefty efforts from countries of the Americas. This remains true to their collective 2030 MMR target while leaving no one behind. These efforts should be mainly directed towards significantly speeding up the tempo of the MMR reduction and applying sensible progressivity, targeting on groups and territories with higher MMR and greater social vulnerabilities, especially in a post-pandemic regional context.

The impact of maternal morbidity on cesarean section rates: exploring a Latin American network of sentinel facilities using the Robson's Ten Group Classification System.

BACKGROUND: Latin America has the highest Cesarean Section Rates (CSR) in the world. Robson's Ten Group Classification System (RTGCS) was developed to enable understanding the CSR in different groups of women, classified according to obstetric characteristics into one of ten groups. The size of each CS group may provide helpful data on quality of care in a determined region or setting. Data can potentially be used to compare the impact of conditions such as maternal morbidity on CSR. The objective of this study is to understand the impact of Severe Maternal Morbidity (SMM) on CSR in ten different groups of RTGCS. METHODS: Secondary analysis of childbirth information from 2018 to 2021, including 8 health facilities from 5 Latin American and Caribbean countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic), using a surveillance database (SIP-Perinatal Information System, in Spanish) implemented in different settings across Latin America. Women were classified into one of RTGCS. The frequency of each group and its respective CSR were described. Furthermore, the sample was divided into two groups, according to maternal outcomes: women without SMM and those who experienced SMM, considering Potentially Life-threatening Conditions, Maternal Near Miss and Maternal Death as the continuum of morbidity. RESULTS: Available data were obtained from 92,688 deliveries using the Robson Classification. Overall CSR was around 38%. Group 5 was responsible for almost one-third of cesarean sections. SMM occurred in 6.7% of cases. Among these cases, the overall CSR was almost 70% in this group. Group 10 had a major role (preterm deliveries). Group 5 (previous Cesarean section) had a very high CSR within the group, regardless of the occurrence of maternal morbidity (over 80%). CONCLUSION: Cesarean section rate was higher in women experiencing SMM than in those without SMM in Latin America. SMM was associated with higher Cesarean section rates, especially in groups 1 and 3. Nevertheless, group 5 was the major contributor to the overall CSR.

Cesarean section in Uruguay from 2008 to 2018: country analysis based on the Robson classification. An observational study.

BACKGROUND: The use of caesarean section has steadily increased, with Latin America being the region with the highest rates. Multiple factors account for that increase and the Robson classification is appropriate to compare determinants at the clinical level for caesarean section rates over time. The purpose of this study is to describe the evolution of caesarean section rates by Robson groups in Uruguay from 2008 to 2018 using a country level database. METHODS: We included the records of all women giving birth in Uruguay (pregnancies ≥22 weeks and weights ≥500 g) with valid data in the mode of childbirth recorded in the Perinatal Information System database between 2008 and 2018. Caesarean section rates were calculated by Robson groups for each of the years included, disaggregated by care sector (public/private) and by geographical area (Capital City/Non-Capital), with time trends and their significance analyzed using linear regression models. RESULTS: Of the total 485,263 births included in this research, the overall caesarean section rate was 43,1%. In 2018, among the groups at lower risk of caesarean section (1 to 4), the highest rates were seen in women in group 2B (98,8%), followed by those in group 4B (97,9%). A significant increase in the number of caesarean sections was seen in groups 2B (97,9 to 98,8%), 3 (8,36 to 11,1%) and 4 (A (22,7 to 26,9%) and B (95,4 to 97,9%) Significant growth was also observed in groups 5 (74,3 to 78,1%), 8 (90,6 to 95,5%), and 10 (39,1 to 46,7%). The private sector had higher rates of caesarean section for all groups throughout the period, except for women in group 9. The private sector in Montevideo presented the highest rates in the groups with the lowest risk of caesarean section (1, 2A, 3 and 4A), followed by the private sector outside of the capital. CONCLUSION: Uruguay is no exception to the increasing caesarean section trend, even in groups of women who have lower risk of requiring caesarean section. The implementation of interventions aimed at reducing caesarean section in the groups with lower obstetric risk in Uruguay is warranted.

Diagnostic performance of two different maternal near-miss approaches in a High Obstetric Risk Unit.

Maternal near-miss (MNM) is a maternal quality care indicator. The World Health Organization (WHO) defines it as a state in which a woman nearly dies but survives due to a complication during pregnancy, birth, or puerperium. The Latin American Federation of Obstetrics and Gynecology (FLASOG) and the Colombian National Health Institute (INS) established recommendations for the event's epidemiological surveillance; nonetheless, the operational definitions of the cases are different. This retrospective study examined the approaches of FLASOG and INS versus the WHO approach (gold standard) for the assessment of MNM in a high obstetric risk unit. Patients admitted with at least one criterion of the WHO, FLASOG, or INS approach for the definition of MNM from March 2016 to March 2017 were included. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were evaluated, as well as the Receiver Operating Characteristics (ROC) curve of the FLASOG and INS. MNM classification compared to WHO system as reference. The results highlight that the WHO classification establishes very high boundaries for some of the diagnostic criteria and the lack of standardization of the MNM criteria among the different proposals in Latin America hinders the applicability in Colombia and other countries with a similar situation.

Status of national policy on companion of choice at birth in Latin America and the Caribbean: Gaps and challenges.

The World Health Organization (WHO) recommends a companion of choice during labor and birth, to improve maternal and perinatal outcomes and women's satisfaction with health services. To better understand the status of companion of choice in Latin America and the Caribbean (LAC), an online survey was conducted with members of a midwifery virtual community of practice and with key informants, aiming to identify: 1) existing regulatory instruments related to companion of choice in the countries where the members are practicing; and, 2) key characteristics of implementation of companion of choice, where regulation exists. Responses (n = 112) were received from representatives of 20 of the 43 countries of LAC. Respondents reported existence of a national policy or legislation in seven countries, ministerial norms or institutional protocols in five countries, and no existing policy/protocol in eight countries. Respondents from the same country often provided contradictory responses. Responses differed from information provided by ministries of health in a WHO-led global policy survey in 11 instances. These variations may reflect that midwives were not always aware of the national policy/guideline in their country. We propose that a more robust effort should be undertaken to understand the status of companion of choice for labor and birth in LAC countries, at national, regional, and local level, in public and private facilities. It is important to know if policies exist, at what level of the system, and if key stakeholders, maternity-care health providers, and women are aware of their existence. Efforts should also be made to understand barriers to implementing companion of choice.

La Organización Mundial de la Salud (OMS) recomienda la presencia de un acompañante durante el trabajo de parto y el parto debido a que mejora los resultados maternos y perinatales y la satisfacción de las mujeres con los servicios de salud. Para comprender mejor la situación acerca de los acompañantes en América Latina y el Caribe (ALC) se llevó a cabo una encuesta en línea dirigida a miembros de una comunidad de práctica de partería e informantes clave con el objetivo de identificar: 1) los instrumentos regulatorios existentes relacionados con la presencia de acompañante en los países en los que ejercen las personas encuestadas y 2) las características clave relacionadas con la implementación del acompañante, en los lugares donde existe un marco regulatorio. Se recibieron 112 respuestas de 20 de los 43 países de ALC. Las personas encuestadas informaron la existencia de una política o legislación nacional en siete países, de normas ministeriales o protocolos institucionales en cinco países, y de la inexistencia de una política o un protocolo en ocho países. Las respuestas provenientes del mismo país a menudo fueron contradictorias, y en 11 casos estas difirieron de la información proporcionada por los ministerios de salud en una encuesta mundial sobre políticas dirigida por la OMS. Estas variaciones pueden reflejar que los profesionales de la partería no siempre conocían la política o el protocolo de su país. Debe emprenderse un esfuerzo más firme para comprender la situación relacionada con el acompañante durante el trabajo de parto y el parto en los países de ALC a nivel nacional, regional y local, tanto en instituciones públicas como privadas. Es importante conocer si existen políticas y en qué nivel del sistema y si los principales interesados, los prestadores de servicios de salud materna y las mujeres conocen su existencia. Se deben realizar esfuerzos para comprender los obstáculos que impiden la implementación de la presencia de un acompañante durante el parto.

A Organização Mundial da Saúde (OMS) recomenda a presença de um acompanhante durante o trabalho de parto e parto, já que essa medida melhora os resultados maternos e perinatais e a satisfação da mulher com os serviços de saúde. Para caracterizar a situação dos acompanhantes na América Latina e Caribe (ALC), realizou-se uma pesquisa on-line com membros de uma comunidade de prática de profissionais de obstetrícia e com informantes chaves para identificar: 1) a existência de instrumentos regulatórios relacionados com a presença de acompanhante nos países onde os respondentes atuam e 2) características chaves relacionadas com a implementação das políticas de acompanhantes nos locais onde existe regulamentação. Foram recebidas 112 respostas de 20 dos 43 países da ALC. Os respondentes relataram a existência de uma política ou legislação nacional em sete países, normas ministeriais ou protocolos institucionais em cinco países e nenhuma política ou protocolo em oito países. Respondentes de um mesmo país deram muitas vezes respostas contraditórias. Em 11 casos, as respostas diferiram das informações fornecidas pelos ministérios da saúde em uma pesquisa de políticas globais realizada pela OMS. Essas variações podem indicar que os profissionais nem sempre conheciam a política ou protocolo em vigor no seu país. Propõe-se a necessidade de iniciativas mais robustas para compreender a situação do acompanhante no trabalho de parto em países da ALC, em nível nacional, regional e local, tanto em instituições públicas como privadas. É importante saber se as políticas existem, em que nível do sistema existem e se as principais partes interessadas, os provedores de cuidados de saúde materna e as mulheres estão cientes de sua existência. São necessários esforços para compreender os obstáculos à implementação do sistema de acompanhante de parto.

COVID-19 and newborn health: systematic review.

OBJECTIVE: To describe perinatal and neonatal outcomes in newborns exposed to SARS-CoV-2. METHODS: A systematic review was conducted by searching PubMed Central, LILACS, and Google Scholar using the keywords 'covid ' AND 'newborn' OR 'child' OR 'infant,' on 18 March 2020, and again on 17 April 2020. One researcher conducted the search and extracted data on demographics, maternal outcomes, diagnostic tests, imaging, and neonatal outcomes. RESULTS: Of 256 publications identified, 20 met inclusion criteria and comprised neonatal outcome data for 222 newborns whose mothers were suspected or confirmed to be SARS-CoV-2 positive perinatally (17 studies) or of newborns referred to hospital with infection/pneumonia (3 studies). Most (12 studies) were case-series reports; all were from China, except three (Australia, Iran, and Spain). Of the 222 newborns, 13 were reported as positive for SARS-CoV-2; most of the studies reported no or mild symptoms and no adverse perinatal outcomes. Two papers among those from newborns who tested positive reported moderate or severe clinical characteristics. Five studies using data on umbilical cord blood, placenta, and/or amniotic fluid reported no positive results. Nine studies reported radiographic imaging, including 5 with images of pneumonia, increased lung marking, thickened texture, or high-density nodular shadow. Minor, non-specific changes in biochemical variables were reported. Studies that tested breast milk reported negative SARS-CoV-2 results. CONCLUSIONS: Given the paucity of studies at this time, vertical transmission cannot be confirmed or denied. Current literature does not support abstaining from breastfeeding nor separating mothers and newborns. Further evidence and data collection networks, particularly in the Americas, are needed for establishing definitive guidelines and recommendations.

Maternal near miss and predictive ability of potentially life-threatening conditions at selected maternity hospitals in Latin America.

BACKGROUND: Every year millions of women around the world suffer from pregnancy, childbirth and postpartum complications. Women who survive the most serious clinical conditions are regarded as to have experienced a severe acute maternal complication called maternal near miss (MNM). Information about MNM cases may complement the data collected through the analysis of maternal death, and was proposed as a helpful tool to identify strengths and weaknesses of health systems in relation to maternal health care. The purpose of this study is to evaluate the performance of a systematized form to detect severe maternal outcomes (SMO) in 20 selected maternity hospitals from Latin America (LAC). METHODS: Cross-sectional study. Data were obtained from analysis of hospital records for all women giving birth and all women who had a SMO in the selected hospitals. Univariate and multivariate adjusted logistic regression models were used to assess the predictive ability of different conditions to identify SMO cases. In parallel, external auditors were hired for reviewing and reporting the total number of discharges during the study period, in order to verify whether health professionals at health facilities identified all MNM and Potentially life-threatening condition (PLTC) cases. RESULTS: Twenty hospitals from twelve LAC were initially included in the study and based on the level of coverage, 11 hospitals with a total of 3,196records were included for the final analysis. The incidence of SMO and MNM outcomes was 12.9 and 12.3 per 1,000 live births, respectively. The ratio of MNM to maternal death was 19 to 1, with a mortality index of 5.1 %. Both univariate and multivariate analysis showed a good performance for a number of clinical and laboratory conditions to predict a severe maternal outcome, however, their clinical relevance remains to be confirmed. Coherence between health professionals and external auditors to identify SMO was high (around 100 %). CONCLUSIONS: The form tested, was well accepted by health professionals and was capable of identifying 100 % of MNM cases and more than 99 % of PLTC variables. Altered state of consciousness, oliguria, placenta accrete, pulmonary edema, and admission to Intensive Care Unit have a high (LR+ ≥80) capacity to anticipate a SMO.

Digital health and the promise of equity in maternity care: A mixed methods multi-country assessment on the use of information and communication technologies in healthcare facilities in Latin America and the Caribbean.

INTRODUCTION: Timely access to maternity care is critical to saving lives. Digital health may serve to bridge the care chasm and advance health equity. Conducted in the aftermath of the COVID-19 pandemic, this cross-sectional mixed-methods study assessed the use of information and communication technologies (ICTs) in healthcare facilities in nine Latin American and Caribbean countries to understand the landscape of ICT use in maternity care and the barriers and facilitators to its adoption. MATERIALS AND METHODS: Between April 2021 and September 2022, we disseminated an online survey in English and Spanish among, mainly public, healthcare institutions that provided maternity care in Argentina, Bolivia, Colombia, the Dominican Republic, Ecuador, Guyana, Honduras, Paraguay and Peru. We also interviewed 27 administrators and providers in ministries of health and healthcare institutions. RESULTS: Most of the 1877 institutions that answered the survey reported using ICTs in maternity care (N = 1536, 82%), ranging from 96% in Peru to 64% in the Dominican Republic. Of institutions that used ICTs, 59% reported using them more than before or for the first time since the pandemic began. ICTs were most commonly used to provide family planning (64%) and breastfeeding (58%) counseling, mainly by phone (82%). At the facility level, availability of equipment and internet coverage, coupled with skilled human resources, were the main factors associated with ICT use. At country level, government-led initiatives to develop digital health platforms, alongside national investments in the digital infrastructure, were the determining factors in the adoption of ICTs in healthcare provision. CONCLUSION: Digital health for maternity care provision relied on commonly available technology and did not necessitate highly sophisticated systems, making it a sustainable and replicable strategy. However, disparities in access to digital health remain and many facilities in rural and remote areas lacked connectivity. Use of ICTs in maternity care depended on countries' long-term commitments to achieving universal health and digital coverage.