Effect of the COVID-19 Pandemic on Stillbirths in Canada and the United States.

OBJECTIVE: There is uncertainty regarding the effect of the COVID-19 pandemic on population rates of stillbirth. We quantified pandemic-associated changes in stillbirth rates in Canada and the United States. METHODS: We carried out a retrospective study that included all live births and stillbirths in Canada and the United States from 2015 to 2020. The primary analysis was based on all stillbirths and live births at ≥20 weeks gestation. Stillbirth rates were analyzed by month, with March 2020 considered to be the month of pandemic onset. Interrupted time series analyses were used to determine pandemic effects. RESULTS: The study population included 18 475 stillbirths and 2 244 240 live births in Canada and 134 883 stillbirths and 22 963 356 live births in the United States (8.2 and 5.8 stillbirths per 1000 total births, respectively). In Canada, pandemic onset was associated with an increase in stillbirths at ≥20 weeks gestation of 1.01 (95% confidence interval [CI] 0.56-1.46) per 1000 total births and an increase in stillbirths at ≥28 weeks gestation of 0.35 (95% CI 0.16-0.54) per 1000 total births. In the United States, pandemic onset was associated with an increase in stillbirths at ≥20 weeks gestation of 0.48 (95% CI 0.22-0.75) per 1000 total births and an increase in stillbirths at ≥28 weeks gestation of 0.22 (95% CI 0.12-0.32) per 1000 total births. The increase in stillbirths at pandemic onset returned to pre-pandemic levels in subsequent months. CONCLUSION: The COVID-19 pandemic's onset was associated with a transitory increase in stillbirth rates in Canada and the United States.

Rural hospital and obstetric unit closures as social determinants of racial and ethnic maternal health disparities: A scoping review.

AIMS: To synthesize literature examining (1) rural hospital or obstetric unit closures as a social determinant of maternal/infant health outcomes and (2) closures as a social determinant of racial/ethnic disparities in maternal/infant health outcomes. DESIGN: Scoping review. DATA SOURCES: MEDLINE, OVID/Embase and CINAHL were searched systematically to identify sources from 31 July 2003 to 31 July 2023. The Arksey and O'Malley methodology for scoping reviews was used. RESULTS: Four studies from the United States and Australia documented the impact of rural hospital or obstetric unit closures on maternal/infant health outcomes, such as increased births in hospitals without obstetric units, out-of-hospital births or babies born before arrival, preterm birth, infant mortality and sociocultural risks that contribute to clinical risk. No eligible studies investigated hospital or obstetric unit closure as a social determinant of racial disparities in rural maternal/infant health outcomes. CONCLUSION: Despite significant racial and ethnic rural maternal health disparities, associations between rural closures and maternal health outcomes for racial and ethnic minorities are understudied. More research is needed to understand the extent to which rural closures, a social determinant of health, could disproportionately, negatively affect the health of racially and ethnically minoritized women. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Rural women have a greater risk of maternal and infant mortality and morbidity compared with urban women, and the impact of rural closures on racial and ethnic maternal health disparities is not well documented. Research about the impact of rural closures on maternal health disparities could inform policy to assure essential obstetric care is available for rural populations globally. IMPACT: Findings provide a call to action for research to understand relationships between rural closures and racial and ethnic maternal health disparities, which is especially important for serving rural Non-Hispanic Black and American Indian/Alaska Native women. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Tradeoff between efficiency and perceived quality: evidence from patient-level data.

OBJECTIVES: To estimate technical efficiency scores of District Headquarter Hospitals (DHQHs) for obstetric services and to explore the relationship between the efficiency of DHQHs and the patients' satisfaction about the quality of services provided. DESIGN, SETTING AND PARTICIPANTS: Data from Health Facility Assessment (HFA) survey is used for efficiency measurement. The data on patient's perceptions and other control variables are taken from Client Exit Interviews part of the HFA survey. Two-stage residual inclusion, Ordered Logistic Regression and Least square dummy variable techniques are used to investigate the relationship between technical efficiency and patients' satisfaction level. MAIN OUTCOME MEASURE(S) AND RESULTS: The average efficiency score for Pakistan's DHQHs is 0.52, and not a single hospital is fully efficient. Moreover, the relationship between technical efficiency and patients' satisfaction is found to be negative and statistically significant indicating that an increase in hospital efficiency tends to decrease patients' satisfaction. The disaggregated analysis reveals that patients' satisfaction associated with the healthcare provider attitude and communication is more affected by technical efficiency. CONCLUSION: Patients' satisfaction level is more sensitive to physician's attitude and communication. This makes sense because the longer the consultation time, the more accurate the diagnosis would be. This, together with a comforting and confident physician, is likely to achieve better patients' satisfaction.

Pregnancy, Labor, and Delivery after Ebola Virus Disease and Implications for Infection Control in Obstetric Services, United States.

Many of the survivors of the 2014-2015 epidemic of Ebola virus disease (EVD) in western Africa were women of childbearing age. Limited clinical and laboratory data exist that describe these women's pregnancies and outcomes. We report the case of an EVD survivor who became pregnant and delivered her child in the United States, and we discuss implications of this case for infection control practices in obstetric services. Hospitals in the United States must be prepared to care for EVD survivors.

Assessment of cesarean delivery availability in 26 low- and middle-income countries: a cross-sectional study.

OBJECTIVE: We sought to assess the capacity to provide cesarean delivery (CD) in health facilities in low- and middle-income countries. STUDY DESIGN: We conducted secondary analysis of 719 health facilities, in 26 countries in Africa, the Pacific, Asia, and the Mediterranean, using facility-based cross-sectional data from the World Health Organization Situational Analysis Tool to Assess Emergency and Essential Surgical Care. RESULTS: A total of 531 (73.8%) facilities reported performing CD. In all, 126 (17.5%) facilities did not perform but referred CD; the most common reasons for doing so were lack of skills (53.2%) and nonfunctioning equipment (42.9%). All health facilities surveyed had at least 1 operating room. Of the facilities performing CD, 47.3% did not report the presence of any type of anesthesia provider and 17.9% did not report the presence of any type of obstetric/gynecological or surgical care provider. In facilities reporting a lack of functioning equipment, 26.4% had no access to an oxygen supply, 60.8% had no access to an anesthesia machine, and 65.9% had no access to a blood bank. CONCLUSION: Provision of CD in facilities in low- and middle-income countries is hindered by a lack of an adequate anesthetic and surgical workforce and availability of oxygen, anesthesia, and blood banks.

Lags in the provision of obstetric services to indigenous women and their implications for universal access to health care in Mexico.

Through quantitative and qualitative methods, in this article the authors describe the perspectives of indigenous women who received antenatal and childbirth medical care within a care model that incorporates a non-governmental organisation (NGO), Partners in Health. They discuss whether the NGO model better resolves the care-seeking process, including access to health care, compared with a standard model of care in government-subsidised health care units (setting of health services networks). Universal health coverage advocates access for the most disadvantaged and vulnerable populations as a priority. However, the issue of access includes problems related to the effect of certain structural social determinants that limit different aspects of the obstetric care process. The findings of this study show the need to modify the structure of organisational values in order to place users at the centre of medical care and ensure respect for their rights. The participation of agents outside the public system, such as NGOs, can be of great value for moving in this direction. Women's participation is also necessary for learning how they are being cared for and the extent to which they are satisfied with obstetric services. This research experience can be used for other countries with similar conditions.

Enabling change in public health services: Insights from the implementation of nurse mentoring interventions to improve quality of obstetric and newborn care in two North Indian states.

Background: Few studies have explicitly examined the implementation of change interventions in low- and middle-income country (LMIC) public health services. We contribute to implementation science by adding to the knowledge base on strategies for implementing change interventions in large, hierarchical and bureaucratic public services in LMIC health systems. Methods: Using a mix of methods, we critically interrogate the implementation of an intervention to improve quality of obstetric and newborn services across 692 facilities in Uttar Pradesh and Bihar states of India to reveal how to go about making change happen in LMIC public health services. Results: We found that focusing the interventions on a discreet part of the health service (labour rooms) ensured minimal disruption of the status quo and created room for initiating change. Establishing and maintaining respectful, trusting relationships is critical, and it takes time and much effort to cultivate such relationships. Investing in doing so allows one to create a safe space for change; it helps thaw entrenched practices, behaviours and attitudes, thereby creating opportunities for change. Those at the frontline of change processes need to be enabled and supported to: lead by example, model and embody desirable behaviours, be empathetic and humble, and make the change process a positive and meaningful experience for all involved. They need discretionary space to tailor activities to local contexts and need support from higher levels of the organisation to exercise discretion. Conclusions: We conclude that making change happen in LMIC public health services, is possible, and is best approached as a flexible, incremental, localised, learning process. Smaller change interventions targeting discreet parts of the public health services, if appropriately contextualised, can set the stage for incremental system wide changes and improvements to be initiated. To succeed, change initiatives need to cultivate and foster support across all levels of the organisation.

Health facility readiness and facility-based birth in Haiti: a maximum likelihood approach to linking household and facility data.

BACKGROUND: Haiti has one of the world's highest maternal mortality ratios. Comprehensive obstetric services could prevent many of these deaths, though most births in Haiti occur outside health facilities. Demand-side factors like a mother's socioeconomic status are understood to affect her access or choice to deliver in a health facility. However, analyses of the role of supply-side factors like health facility readiness have been constrained by limited data and methodological challenges. We sought to address these challenges and determine whether Haiti could increase rates of facility-based birth by improving facility readiness to provide delivery services. METHODS: Our task was to characterize facility delivery readiness and link it to nearby births. We used birth data from the 2012 Haiti DHS and facility data from the 2013 Haiti SPA. Our outcome of interest was facility-based birth. Our predictor of interest was delivery readiness at the DHS sampling cluster level. We derived a novel likelihood function that used Kernel Density Estimation to estimate cluster-level readiness alongside the coefficients of a logistic regression. RESULTS: We analyzed data from 389 facilities and 1,991 births. Rural facilities were less ready than urban facilities to provide delivery services. Women delivering in health facilities were younger, more educated, wealthier, less likely to live in rural areas, and had fewer previous children. Our model estimated that rural facilities (σ = 12.28, standard error [SE] = 0.16) spread their readiness over larger areas than urban facilities (σ = 7.14, SE = 0.016). Cluster-level readiness was strongly associated with facility-based birth (adjusted log-odds = 0.031; p = 0.005), as was socioeconomic status (adjusted log-odds = 0.78; p < 0.001). CONCLUSIONS: Health system policymakers in Haiti could increase rates of facility-based birth by supporting targeted interventions to improve facility readiness to provide delivery-related services, alongside efforts to reduce poverty and increase educational attainment among women.

Availability, utilization, and quality of emergency obstetric care services in Bauchi State, Nigeria.

OBJECTIVE: To report the availability, utilization, and quality of emergency obstetric care (EmOC) services in Bauchi State, Nigeria. METHODS: Between June and July 2012, a cross-sectional survey of health facilities was conducted. Data on the performance of EmOC services between June 2011 and May 2012 were obtained from records of 20 general hospitals and 39 primary healthcare centers providing delivery services. Additionally, structured interviews with facility managers were conducted. RESULTS: Only 6 (10.2%) of the 59 facilities met the UN requirements for EmOC centers. None of the three senatorial zones in Bauchi State had the minimum acceptable number of five EmOC facilities per 500 000 population. Overall, 10 517 (4.4%) of the estimated 239 930 annual births took place in EmOC facilities. Cesarean delivery accounted for 3.6% (n=380) of the 10 517 births occurring in EmOC facilities and 0.2% of the 239 930 expected live births. Only 1416 (3.9%) of the expected 35 990 obstetric complications were managed in EmOC facilities. Overall, 45 (3.2%) of 1416 women with major direct obstetric complications treated at EmOC facilities died. Among 379 maternal deaths, 317 (83.6%) were attributable to major direct obstetric complications. CONCLUSION: Availability, utilization, and quality of EmOC services in Bauchi State, Nigeria, are suboptimal. The health system's capacity to manage emergency obstetric complications needs to be strengthened.

Concordância interavaliadores do Protocolo de Acolhimento e Classificação de Risco em Obstetrícia do Ministério da Saúde / Inter-rater agreement of the Reception Protocol and Risk Classification in Obstetrics of the Ministry of Health

Introdução: A classificação de risco é definida como uma ferramenta utilizada nos serviços de urgência e emergência que auxilia na identificação de pacientes que necessitam atendimento prioritário. Em obstetrícia o surgimento de um protocolo específico por intermédio do Ministério da Saúde que conta com 12 fluxogramas tem sido uma medida adotada para organização e humanização dos serviços que atendem obstetrícia, no intuito de minimizar danos relacionados à saúde dessas usuárias que aguardam atendimento . O objetivo do estudo foi: determinar o grau de concordância interavaliador na aplicação do protocolo de acolhimento e classificação de risco em obstetrícia do Ministério da Saúde em uma unidade de pronto atendimento obstétrico. Métodos: Trata-se de um estudo transversal, com abordagem metodológica, que analisou a reprodutibilidade do protocolo em obstetrícia do Ministério da saúde. Para a coleta dos dados: foram avaliados prontuários com o registro de atendimentos ocorridos entre novembro 2019 e maio de 2020. Foram entrevistados enfermeiros que possuem treinamento em classificação de risco e também enfermeiros que não possuem treinamento em classificação de risco. Para análise estatística dos dados foram calculados através do coeficiente de Kappa, sensibilidade e especificidade. Resultados: Os resultados do estudo demonstraram que o grau de confiabilidade interavaliadores foi considerado de moderado a forte representado pelo coeficiente Kappa que variou entre (0,47 e 0,77), foi observado também uma tendência na subestimação do grupo prioritário vermelho e amarelo, e uma tendência de superestimação nas prioridades clínicas amarelo e verde. Apesar de ter acontecido casos de subestimação e superestimação não ocorreram diferenças significativas nos grupos de enfermeiros treinados versus não treinados para utilização do protocolo de A&CR-O. Assim, os resultados desta dissertação corroboram com a hipótese que o protocolo de A&CR ­ O é confiável para o que se propõe. Conclusão: Esse estudo possibilitou verificar que o protocolo é confiável para sua utilização no campo da obstetrícia, uma vez que demonstrou concordância moderada a forte entre os grupos de avaliadores, além disso contribuiu para a análise da reprodutibilidade do protocolo de classificação de risco em obstetrícia que vem sendo implantado desde se sua publicação podendo ser utilizado com maior segurança por Enfermeiros. Palavras-chave: Protocolos. Protocolos clínicos. Confiabilidade. Obstetrícia. Classificação de risco. Serviços de emergência obstétrica. Reprodutibilidade. Enfermagem. Enfermagem Obstétrica. Estudos de avaliação.

Introduction: Risk classification is defined as a tool used in urgent and emergency services that helps to identify patients who need priority care. In obstetrics, the emergence of a specific protocol through the Ministry of Health, which has 12 flowcharts, has been a measure adopted to organize and humanize the services that attend obstetrics, in order to minimize the health-related damage of these users who are awaiting care. The objective of the study was: to determine the degree of inter-rater agreement in the application of the welcoming protocol and risk classification in obstetrics of the Ministry of Health in an obstetric emergency care unit. Methods: This is a cross-sectional study, with a methodological approach, which analyzed the reproducibility of the protocol in obstetrics of the Ministry of Health. For data collection: medical records were evaluated with the record of visits that took place between November 2019 and May 2020. Nurses who have training in risk classification and nurses who do not have training in risk classification were interviewed. For statistical analysis of the data, they were calculated using the Kappa coefficient, sensitivity and specificity. Results: The results of the study showed that the degree of inter-rater reliability was considered moderate to strong, represented by the Kappa coefficient that varied between (0.47 and 0.77), a tendency was also observed in the underestimation of the red and yellow priority group, and a tendency to overestimate the yellow and green clinical priorities. Despite cases of underestimation and overestimation, there were no significant differences in the groups of trained versus untrained nurses to use the A & CR-O protocol. Thus, the results of this dissertation corroborate the hypothesis that the A&CR - O protocol is reliable for what it is proposed. Conclusion: This study made it possible to verify that the protocol is reliable for its use in the field of obstetrics, since it demonstrated mode rate to strong agreement between the groups of evaluators, in addition it contributed to the analysis of the reproducibility of the risk classification protocol in obstetrics that it has been implemented since its publication and can be used more safely by nurses.

Uptake of voluntary counselling and testing for HIV by pregnant women in a prevention-of-mother-to-child-transmission programme at Aminu Kano Teaching Hospital, Nigeria.

Mother-to-child transmission is the main mode of HIV infection among children in developing countries. In 2003, as a result of government policy, a prevention-of-mother-to-child-transmission (PMTCT) programme was introduced at Aminu Kano Teaching Hospital in Nigeria. The aim of this study was to determine the pattern of voluntary counselling and testing (VCT) uptake and HIV seroprevalence among pregnant women using the service. VCT has become part of routine antenatal care at the hospital; in addition, antiretroviral prophylaxis/treatment, modification of obstetric practices, and counselling on infant feeding options are provided for HIV-positive pregnant women. Data on clients' socio-demographic characteristics, VCT uptake, and HIV seropositivity for a three-year period (from January 2004 to December 2006) were taken from nationally prepared PMTCT registers kept at the hospital, and prospectively entered into a database. During the period, 6 887 women newly accessed antenatal care (i.e. repeat pregnancies were excluded). All the women were group counselled, and 6 702 (97.3%) agreed to undergo HIV testing. Overall HIV prevalence among these pregnant women for the study period was 5.9% (95% CI 5.2-6.3%). The data have shown a statistically significant trend of rising HIV prevalence in this group: at 4.5%, prevalence was lowest in 2004; rose to 4.9% in 2005; and peaked at 7.6% in 2006 (χ(2) trend = 21.9; p < 0.001). Overall HIV seroprevalence was 3.5% among 15- to 19-year-old women, 7% among 25- to 29-year-old women, and 4.5% among women over age 40. There was an inverse relationship between parity (number of children borne) and HIV seroprevalence such that women of low parity had high HIV prevalence, and vice versa (χ(2) trend = 13.1; p < 0.01). Respectively, 11.4%, 5.7%, and 5.5% of the pregnant women first using VCT in the first, second, and third trimesters of their pregnancy were found to be HIV-positive. All women testing HIV-positive were informed of their serostatus and the modes of preventing mother-to-child transmission of HIV. There is a relatively high uptake of VCT for PMTCT at this tertiary hospital, while an increasingly higher proportion of HIV-positive pregnant women are being identified and provided with opportunities to prevent HIV transmission to their babies. PMTCT should be universally accessible to women in developing countries.