Stillbirth rates and their determinants in a national maternity hospital in Phnom Penh, Cambodia in 2017-2020: a cross-sectional assessment with a nested case-control study.

BACKGROUND: In Cambodia, stillbirths and their underlying factors have not been systematically studied. This study aimed to assess the proportion and trends in stillbirths between 2017 and 2020 in a large maternity referral hospital in the country and identify their key determinants to inform future prevention efforts. METHODS: This was a retrospective cross-sectional analysis with a nested case-control study of women giving birth at the National Maternal and Child Health Centre (NMCHC) in Phnom Penh, 2017-2020. We calculated percentages of singleton births at ≥ 22 weeks' gestation resulting in stillbirth and annual stillbirth rates by timing: intrapartum (fresh) or antepartum (macerated). Multivariable logistic regression was used to explore factors associated with stillbirth, where cases were all women who gave birth to a singleton stillborn baby in the 4-year period. One singleton live birth immediately following each case served as an unmatched control. Multiple imputation was used to handle missing data for gestational age. RESULTS: Between 2017 and 2020, 3.2% of singleton births ended in stillbirth (938/29,742). The stillbirth rate increased from 24.8 per 1000 births in 2017 to 38.1 per 1000 births in 2020, largely due to an increase in intrapartum stillbirth rates which rose from 18.8 to 27.4 per 1000 births in the same period. The case-control study included 938 cases (stillbirth) and 938 controls (livebirths). Factors independently associated with stillbirth were maternal age ≥ 35 years compared to < 20 years (aOR: 1.82, 95%CI: 1.39, 2.38), extreme (aOR: 3.29, 95%CI: 2.37, 4.55) or moderate (aOR: 2.45, 95%CI: 1.74, 3.46) prematurity compared with full term, and small-for-gestational age (SGA) (aOR: 2.32, 1.71, 3.14) compared to average size-for-age. Breech/transverse births had nearly four times greater odds of stillbirth (aOR: 3.84, 95%CI: 2.78, 5.29), while caesarean section reduced the odds by half compared with vaginal birth (aOR: 0.50, 95%CI: 0.39, 0.64). A history of abnormal vaginal discharge increased odds of stillbirth (aOR: 1.42, 95%CI: 1.11, 1.81) as did a history of stillbirth (aOR: 3.08, 95%CI: 1.5, 6.5). CONCLUSIONS: Stillbirth prevention in this maternity referral hospital in Cambodia requires strengthening preterm birth detection and management of SGA, intrapartum care, monitoring women with stillbirth history, management of breech births, and further investigation of high-risk referral cases.

In Cambodia, there is very little information published on stillbirths to know precisely how many there are and to understand the underlying reasons they occur so they can be prevented in the future. Our study aimed to quantify the number of stillborn babies and identify some underlying risk factors from one of the largest maternity referral hospitals in Phnom Penh, Cambodia. We examined data from almost 30,000 health facility medical files of women who gave birth between 2017 and 2020 which included 938 stillbirths. We found that about 3.2% of births ended in a stillbirth and that this percentage increased between 2017 and 2020. Women who had preterm babies, or whose babies were small in weight for their gestational age, and babies that were born breech had a higher chance of being stillborn. Women who had abnormal vaginal discharge, which can indicate a possible infection, also had a higher odds of having a stillbirth. We also found that women who had a stillbirth previously had almost three times higher chance of having another stillborn baby. Having a caesarean section reduced the likelihood of having a stillborn baby by about half. These findings suggest that efforts are needed to better identify and manage women with preterm births and monitor fetal growth as well as ensure breech births are managed adequately.

Changes over time in HIV testing and counselling uptake and associated factors among youth in Zambia: a cross-sectional analysis of demographic and health surveys from 2007 to 2018.

INTRODUCTION: Zambia is among the countries with the highest HIV burden and where youth remain disproportionally affected. Access to HIV testing and counselling (HTC) is a crucial step to ensure the reduction of HIV transmission. This study examines the changes that occurred between 2007 and 2018 in access to HTC, inequities in testing uptake, and determinants of HTC uptake among youth. METHODS: We carried out repeated cross-sectional analyses using three Zambian Demographic and Health Surveys (2007, 2013-14, and 2018). We calculated the percentage of women and men ages 15-24 years old who were tested for HIV in the last 12 months. We analysed inequity in HTC coverage using indicators of absolute inequality. We performed bivariate and multivariate logistic regression analyses to identify predictors of HTC uptake in the last 12 months. RESULTS: HIV testing uptake increased between 2007 and 2018, from 45 to 92% among pregnant women, 10 to 58% among non-pregnant women, and from 10 to 49% among men. By 2018 roughly 60% of youth tested in the past 12 months used a government health centre. Mobile clinics were the second most common source reaching up to 32% among adolescent boys by 2018. Multivariate analysis conducted among men and non-pregnant women showed higher odds of testing among 20-24 year-olds than adolescents (aOR = 1.55 [95%CI:1.30-1.84], among men; and aOR = 1.74 [1.40-2.15] among women). Among men, being circumcised (aOR = 1.57 [1.32-1.88]) and in a union (aOR = 2.44 [1.83-3.25]) were associated with increased odds of testing. For women greater odds of testing were associated with higher levels of education (aOR = 6.97 [2.82-17.19]). Education-based inequity was considerably widened among women than men by 2018. CONCLUSION: HTC uptake among Zambian youth improved considerably by 2018 and reached 65 and 49% tested in the last 12 months for women and men, respectively. However, achieving the goal of 95% envisioned by 2020 will require sustaining the success gained through government health centres, and scaling up the community-led approaches that have proven acceptable and effective in reaching young men and adolescent girls who are less easy to reach through the government facilities.

Knowledge on intrapartum care practices among skilled birth attendants in Cambodia-a cross-sectional study.

BACKGROUND: Delivery is a critical moment for pregnant women and babies, and careful monitoring is essential throughout the delivery process. The partograph is a useful tool for monitoring and assessing labour progress as well as maternal and foetal conditions; however, it is often used inaccurately or inappropriately. A gap between practices and evidence-based guidelines has been reported in Cambodia, perhaps due to a lack of evidence-based knowledge in maternity care. This study aims to address to what extent skilled birth attendants in the first-line health services in Cambodia have knowledge on the management of normal delivery, and what factors are associated with their level of knowledge. METHODS: Midwives and nurses were recruited working in maternity in first-line public health facilities in Phnom Penh municipality, Kampong Cham and Svay Rieng provinces. Two self-administered questionnaires were applied. The first consisted of three sections with questions on monitoring aspects of the partograph: progress of labour, foetal, and maternal conditions. The second consisted of questions on diagnostic criteria, normal ranges, and standard intervals of monitoring during labour. A multiple linear regression analysis was performed to identify relationships between characteristics of the participants and the questionnaire scores. RESULTS: Of 542 eligible midwives and nurses, 523 (96%) participated. The overall mean score was 58%. Only 3% got scores of more than 90%. Multivariate analysis revealed that 'Kampong Cham province', 'younger age', and 'higher qualification' were significantly associated with higher scores. Previous training experience was not associated with the score. Substantial proportions of misclassification of monitoring items during labour were found; for example, 61% answered uterine contraction as a foetal condition, and 44% answered foetal head descent and 26% answered foetal heart rate as a maternal condition. CONCLUSION: This study found that knowledge was low on delivery management among skilled birth attendants. Previous training experience did not influence the knowledge level. A lack of understanding of physiology and anatomy was implied. Further experimental approaches should be attempted to improve the knowledge and quality of maternity services in Cambodia.

Pregnancy and childbirth are natural phenomena, but sometimes have risk for mothers and babies. Therefore, childbirth should be carefully and continuously monitored by the health care professional. The 'partograph' is a useful tool that defines three monitoring aspects of the delivery progress, and conditions of the mother and intrauterine baby. However, it is often used inaccurately or inappropriately in low- and middle-income countries. We hypothesised that health professionals who assist childbirth cannot effectively monitor delivery conditions because their knowledge is insufficient. Therefore, we evaluated the knowledge on monitoring the process of childbirth and explored factors which affect the level of knowledge among health care providers in Cambodia.Midwives and nurses were targeted in this study who deal with normal deliveries in the capital city and two provinces. The questionnaire was designed to evaluate if their knowledge on three monitoring aspects is accurate.Of 542 eligible personnel, 523 (96%) participated. The mean score was 58%. Only 3% got scores of more than 90%. According to the statistical analysis, 'working in Kampong Cham province', 'younger age', and 'higher qualification' were significantly associated with higher scores. Previous training experience was not associated with the score.This study found that basic knowledge was low on delivery management among health care providers. We suspect that a deficiency of basic medical knowledge, such as physiology and anatomy, causes the lack of knowledge on the childbirth process. Further intervention should be attempted to improve the knowledge and quality of maternity services in Cambodia.

Evidence-based intrapartum practice and its associated factors at a tertiary teaching hospital in the Philippines, a descriptive mixed-methods study.

BACKGROUND: Evidenced-based practice is a key component of quality care. However, studies in the Philippines have identified gaps between evidence and actual maternity practices. This study aims to describe the practice of evidence-based intrapartum care and its associated factors, as well as exploring the perceptions of healthcare providers in a tertiary hospital in the Philippines. METHODS: A mixed-methods study was conducted, which consisted of direct observation of intrapartum practices during the second and third stages, as well as semi-structured interviews and focus group discussions with care providers to determine their perceptions and reasoning behind decisions to perform episiotomy or fundal pressure. Univariate and multivariate logistic regression were used to analyse the relationship between observed practices and maternal, neonatal, and environmental factors. Qualitative data were parsed and categorised to identify themes related to the decision-making process. RESULTS: A total of 170 deliveries were included. Recommended care, such as prophylactic use of oxytocin and controlled cord traction in the third stage, were applied in almost all the cases. However, harmful practices were also observed, such as intramuscular or intravenous oxytocin use in the second stage (14%) and lack of foetal heart rate monitoring (57%). Of primiparae, 92% received episiotomy and 31% of all deliveries received fundal pressure. Factors associated with the implementation of episiotomy included primipara (adjusted Odds Ratio [aOR] 62.3), duration of the second stage of more than 30 min (aOR 4.6), and assisted vaginal delivery (aOR 15.0). Factors associated with fundal pressure were primipara (aOR 3.0), augmentation with oxytocin (aOR 3.3), and assisted delivery (aOR 4.8). Healthcare providers believe that these practices can prevent laceration. The rate of obstetric anal sphincter injuries (OASIS) was 17%. Associated with OASIS were assisted delivery (aOR 6.0), baby weights of more than 3.5 kg (aOR 7.8), episiotomy (aOR 26.4), and fundal pressure (aOR 6.2). CONCLUSIONS: Our study found that potentially harmful practices are still conducted that contribute to the occurrence of OASIS. The perception of these practices is divergent with current evidence, and empirical knowledge has more influence. To improve practices the scientific evidence and its underlying basis should be understood among providers.

A descriptive study of stroke types, risk factors, clinical features, and outcomes in a tertiary hospital in Myanmar.

BACKGROUND: Stroke is a leading cause of death in the world, and the burden of stroke is higher in low- and middle-income countries. Understanding the risk factors, complications, and outcomes of stroke are useful for healthcare planning and resource allocation. Little information on stroke is available for many low- and middle-income Asian countries; including Myanmar, which is the focus of this study. METHODS: A review was conducted of medical records for stroke admissions during 2017 in a tertiary hospital in Myanmar. The final diagnoses, risk factors, clinical features, complications, and outcomes were systematically collected from computer- and paper-based medical records. RESULTS: Of 908 cases analysed, haemorrhagic stroke was the most common type (49%), followed by ischaemic stroke (43%). Unimproved cases were 32%. Identified risk factors of unimproved cases were 'haemorrhagic stroke' [adjusted odds ratio (aOR): 1.73], 'having fever during hospitalization' [aOR: 2.49], 'Glasgow Coma Scale (GCS) at the admission between 9 and 14' [aOR: 4.33], and GCS less than 9 [aOR: 42.86]. CONCLUSION: This study is based on hospital medical records to assess stroke types, risk factors, clinical features, and outcomes in a tertiary hospital, in Nay Pyi Daw, Myanmar. The findings indicated that early case admission, improved hospital care management, and increased awareness of the modifiable risk factors within populations are crucial for preventing stroke incidents.

Cardiotocography use for fetal assessment during labor in low- and middle-income countries: A scoping review.

BACKGROUND: The use of cardiotocography (CTG) to improve neonatal outcomes is controversial. The medical settings, subjects, utilizations, and interpretation guidelines of CTG are unclear for low- and middle-income countries (LMICs). OBJECTIVES: To assess and review CTG use for studies identified in LMICs and provide insights on the potential for effective use of CTG to improve maternal and neonatal outcomes. SEARCH STRATEGY: The databases Medline, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for published and unpublished literature through September 2023. SELECTION CRITERIA: Publications were identified which were conducted in LMICs, based on the World Bank list of economies for 2019; targeting pregnant women in childbirth; and focusing on the utilization of CTG and neonatal outcomes. DATA COLLECTION AND ANALYSIS: Publications were screened, and duplicates were removed. A scoping review was conducted using PRISMA-ScR guidelines. RESULTS: The searches generated 1157 hits, of which 67 studies were included in the review. In the studies there was considerable variation and ambiguity regarding the study settings, target populations, utilizations, timing, frequency, and duration of CTG. While cesarean section rates were extensively investigated as an outcome of studies of CTG itself and the effect of additional techniques on CTG, other clinically significant outcomes, including neonatal mortality, were not well reported. CONCLUSIONS: Variations and ambiguities were found in the use of CTG in LMICs. Due to the limited amount of evidence, studies are needed to examine CTG availability in the context of LMICs.

Coinfections of malaria and sexually transmitted and reproductive tract infections in pregnancy in sub-Saharan Africa: a systematic review and individual participant data meta-analysis protocol.

INTRODUCTION: Malaria infection and curable sexually transmitted infections and reproductive tract infections (STIs/RTIs) adversely impact pregnancy outcomes. In sub-Saharan Africa, the prevalence of malaria and curable STIs/RTIs is high and, where coinfection is common, combination interventions may be needed to improve pregnancy outcomes. The aim of this systematic review is to estimate the prevalence of malaria and curable STI/RTI coinfection during pregnancy, risk factors for coinfection and prevalence of associated adverse pregnancy outcomes. METHODS AND ANALYSIS: We will use three electronic databases, PubMed, EMBASE and Malaria in Pregnancy Library to identify studies involving pregnant women attending routine antenatal care facilities in sub-Saharan Africa and reporting malaria and curable STI/RTI test results, published in any language since 2000. We will search databases in the second quarter of 2023 and repeat the search before completion of our analyses. The first two authors will screen titles and abstracts, selecting studies that meet inclusion criteria and qualify for full-text screening. If agreement on inclusion/exclusion cannot be reached, the last author will serve as arbiter. We will extract data from eligible publications for a study-level meta-analysis. We will contact research groups of included studies and request individual participant data for meta-analysis. The first two authors will conduct a quality appraisal of included studies using the GRADE system. The last author will adjudicate if the first two authors do not agree on any appraisals. We will conduct sensitivity analyses to test the robustness of effect estimates over time (by decade and half-decade periods), geography (East/Southern Africa vs West/Central Africa), gravidity (primigravidae, secundigravidae, multigravidae), treatment type and dosing frequency, and malaria transmission intensity. ETHICS AND DISSEMINATION: We obtained ethics approval from the London School of Hygiene & Tropical Medicine (LSHTM Ethics Ref: 26167). Results of this study will be disseminated via peer-reviewed publication and presentation at scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42021224294.

Modern contraceptive use among adolescent girls and young women in Benin: a mixed-methods study.

OBJECTIVES: The study aimed to assess the determinants of modern contraceptive method use among young women in Benin. DESIGN: A mixed-methods design. SETTING AND PARTICIPANTS: We used the Benin 2017-2018 Demographic and Health Survey datasets for quantitative analysis. Data collection was conducted using multiple-cluster sampling method and through household survey. Qualitative part was conducted in the city of Allada, one of the Fon cultural capitals in Benin. The participants were purposively selected. OUTCOMES: Contraceptive prevalence rate, unmet need for modern method and percentage of demand satisfied by a modern method for currently married and sexually active unmarried women were measured in the quantitative part. Access barriers and utilisation of modern methods were assessed in the qualitative part. RESULTS: Overall, 8.5% (95% CI 7.7% to 9.5%) among young women ages 15-24 were using modern contraceptives and 13% (12.1% to 14.0%) among women ages 25 or more. Women 15-24 had a higher unmet need, and a lower demand satisfied by modern contraceptive methods compared with women ages 25 or more. 60.8% (56.9% to 64.7%) of all unmarried young women had unmet need for modern contraceptives. Young women were more likely to use male condoms which they obtain mainly from for-profit outlets, pharmacies and relatives. The factors associated with demand satisfied by a modern method were literacy, being unmarried, knowing a greater number of modern contraceptive methods and experiencing barriers in access to health services. On the other hand, the qualitative study found that barriers to using modern methods include community norms about pre-marital sexual intercourse, perceptions about young women's fertility, spousal consent and the use of non-modern contraceptives. CONCLUSION: Contraceptive use is low among young women in Benin. The use of modern contraceptives is influenced by sociodemographic factors and social norms. Appropriate interventions might promote comprehensive sexuality education, increase community engagement, provide youth-friendly services and address gender inequalities.

Affordability of emergency obstetric and neonatal care at public hospitals in Madagascar.

Timely access to emergency obstetric care is necessary to save the lives of women experiencing complications at delivery, and for newborn babies. Out-of-pocket costs are one of the critical factors hindering access to such services in low- and middle-income countries. This study measured out-of-pocket costs for caesarean section and neonatal care at an urban tertiary public hospital in Madagascar, assessed affordability in relation to household expenditure and investigated where families found the money to cover these costs. Data were collected for 103 women and 73 newborns at the Centre Hospitalier Universitaire de Mahajanga in the Boeny region of Madagascar between September 2007 and January 2008. Out-of-pocket costs for caesarean section were catastrophic for middle and lower socio-economic households, and treatment for neonatal complications also created a big financial burden, with geographical and other financial barriers further limiting access to hospital care. This study identified 12 possible cases where the mother required an emergency caesarean section and her newborn required emergency care, placing a double burden on the household. In an effort to make emergency obstetric and neonatal care affordable and available to all, including those living in rural areas and those of medium and lower socio-economic status, well-designed financial risk protection mechanisms and a strong commitment by the government to mobilise resources to finance the country's health system are necessary.

"Why did our baby die soon after birth?"-Lessons on neonatal death in rural Cambodia from the perspective of caregivers.

INTRODUCTION: Neonatal deaths represent around half the deaths of children less than five-years old in Cambodia. The process from live birth to neonatal death has not been well described. This study aimed to identify problems in health care service which hamper the reduction of preventable neonatal deaths in rural Cambodia. METHODS: This study adopted a method of qualitative case study design using narrative data from the verbal autopsy standard. Eighty and forty villages were randomly selected from Kampong Cham and Svay Rieng provinces, respectively. All households in the target villages were visited between January and February 2017. Family caregivers were asked to describe their experiences on births and neonatal deaths between 2015 and 2016. Information on the process from birth to death was extracted with open coding, categorized, and summarized into several groups which represent potential problems in health services. RESULTS: Among a total of 4,142 children born in 2015 and 2016, 35 neonatal deaths were identified. Of these deaths, 74% occurred within one week of birth, and 57% were due to low-birth weight. Narrative data showed that three factors should be improved, 1) the unavailability of a health-care professional, 2) barriers in the referral system, and 3) lack of knowledge and skill to manage major causes of neonatal deaths. CONCLUSION: The current health system has limitations to achieve further reduction of neonatal deaths in rural Cambodia. The mere deployment of midwives at fixed service points such as health centers could not solve the problems occurring in rural communities. Community engagement revisiting the principle of primary health care, as well as health system transformation, is the key to the solution and potential breakthrough for the future.

Determinants of growth measurements in rural Cambodian infants: a cross-sectional study.

BACKGROUND: Inappropriate feeding and hygiene practices and poor environment are associated with malnutrition. We aimed to investigate the contributions of feeding, hygiene practices and recent illness to the nutritional status of rural Cambodian infants and any sex-specific differences. METHODS: In a cross-sectional study, nested within an ongoing birth cohort, trained fieldworkers conducted anthropometry and collected information from the main caregiver during home visits. Multivariable linear regression was used to investigate associations with nutritional status as length-for-age z-scores (LAZ) and weight-for-length z-scores (WLZ). RESULTS: A total of 156 children, 87 (55.8%) male, ages 0-11 months were enrolled. The prevalence of acute malnutrition (WLZ <-2) in males and females was 2.3% (2/87) and 5.8% (4/69), respectively, and 23.0% (20/87) of males and 14.5% (10/69) of females were stunted (LAZ <-2). WLZ but not LAZ decreased with age. WLZ was independently negatively associated with increasing age (ß-coefficient -0.14 [95% confidence interval {CI} -0.20 to -0.08], p<0.001), and regular use of feeding bottles (ß-coefficient -0.46 [95% CI -0.83 to -0.10], p=0.014), and positively with handwashing with soap (ß-coefficient 0.40 [95% CI 0.05 to 0.75), p=0.027). CONCLUSIONS: The prevalence of acute malnutrition was low, but stunting was prevalent without evidence of a sex difference. Non-linear growth faltering was associated with increasing age and hygiene/feeding practices.

Factors affecting the choice of delivery place in a rural area in Laos: A qualitative analysis.

BACKGROUND: Home delivery (HD) without skilled birth attendants (SBAs) are considered crucial risk factors increasing maternal and child mortality rates in Loa PDR. While a few studies in the literature discuss the choice of delivery in remote areas of minority ethnic groups; our work aims to identify factors that indicated their delivery place, at home or in the health facilities. METHODS: A community-based qualitative study was conducted between February and March 2020. Three types of interviews were implemented, In-depth interviews with 16 women of eight rural villages who delivered in the last 12 months in Xepon District, Savannakhet Province, Lao PDR. Also, three focus group discussions (FGDs) with nine HCPs and key-informant interviews of ten VHVs were managed. Factors affecting the choice of the delivery place were categorized according to the social-ecological model. RESULTS: Our sample included five Tri women and two Mangkong women in the HD group, while the FD group included three Tri women, two Mangkong women, one Phoutai woman, two Laolung women and one Vietnamese. Our investigation inside the targeted minority showed that both positive perceptions of home delivery (HD) and low-risk perception minorities were the main reasons for the choice of HD, on the individual level. On the other hand, fear of complication, the experience of stillbirth, and prolonged labour pain during HD were reasons for facility-based delivery (FD). Notably, the women in our minority reported no link between their preference and their language, while the HCPs dated the low knowledge to the language barrier. On the interpersonal level, the FD women had better communication with their families, and better preparation for delivery compared to the HD group. The FD family prepared cash and transportation using their social network. At the community level, the trend of the delivery place had shifted from HD to FD. Improved accessibility and increased knowledge through community health education were the factors of the trend. At the societal (national policy) level, the free delivery policy and limitation of HCPs' assisted childbirth only in health facilities were the factors of increasing FD, while the absence of other incentives like transportation and food allowance was the factor of remaining of HD. CONCLUSIONS: Based on the main findings of this study, we urge the enhancement of family communication on birth preparedness and birthplace. Furthermore, our findings support the need to educate mothers, especially those of younger ages, about their best options regarding the place of delivery. We propose implementing secondary services of HD to minimize the emergency risks of HD. We encourage local authorities to be aware of the medical needs of the community especially those of pregnant females and their right for a free delivery policy.

Awareness and preparedness of healthcare workers against the first wave of the COVID-19 pandemic: A cross-sectional survey across 57 countries.

BACKGROUND: Since the COVID-19 pandemic began, there have been concerns related to the preparedness of healthcare workers (HCWs). This study aimed to describe the level of awareness and preparedness of hospital HCWs at the time of the first wave. METHODS: This multinational, multicenter, cross-sectional survey was conducted among hospital HCWs from February to May 2020. We used a hierarchical logistic regression multivariate analysis to adjust the influence of variables based on awareness and preparedness. We then used association rule mining to identify relationships between HCW confidence in handling suspected COVID-19 patients and prior COVID-19 case-management training. RESULTS: We surveyed 24,653 HCWs from 371 hospitals across 57 countries and received 17,302 responses from 70.2% HCWs overall. The median COVID-19 preparedness score was 11.0 (interquartile range [IQR] = 6.0-14.0) and the median awareness score was 29.6 (IQR = 26.6-32.6). HCWs at COVID-19 designated facilities with previous outbreak experience, or HCWs who were trained for dealing with the SARS-CoV-2 outbreak, had significantly higher levels of preparedness and awareness (p<0.001). Association rule mining suggests that nurses and doctors who had a 'great-extent-of-confidence' in handling suspected COVID-19 patients had participated in COVID-19 training courses. Male participants (mean difference = 0.34; 95% CI = 0.22, 0.46; p<0.001) and nurses (mean difference = 0.67; 95% CI = 0.53, 0.81; p<0.001) had higher preparedness scores compared to women participants and doctors. INTERPRETATION: There was an unsurprising high level of awareness and preparedness among HCWs who participated in COVID-19 training courses. However, disparity existed along the lines of gender and type of HCW. It is unknown whether the difference in COVID-19 preparedness that we detected early in the pandemic may have translated into disproportionate SARS-CoV-2 burden of disease by gender or HCW type.

Challenges to neonatal care in Cambodia amid the COVID-19 pandemic.

Since mid-February, 2020, coronavirus disease-2019 (COVID-19) has been spreading in Cambodia and, as of April 9, 2020, the Ministry of Health has identified 119 polymerase chain reaction (PCR)-positive cases. However, the PCR test is available in only two specialized institutes in the capital city Phnom Penh; therefore, exact and adequate identification of the cases remains still limited. Many vulnerable newborn infants have been admitted to the neonatal care unit (NCU) at the National Maternal and Child Health Center in Phnom Penh. Although the staff have implemented strict infection prevention and control measures, formidable gaps in neonatal care between Cambodia and Japan exist. Due to the shortages in professional workforce, one family member of sick newborn(s) should stay for 24 hours in the NCU to care for the baby. This situation, however, may lead to several errors, including hospital-acquired infection. It is crucial not only to make all efforts to prevent infections but also to strengthen the professional healthcare workforce instead of relying on task sharing with family members.

Frequent unregulated use of antibiotics in rural Cambodian infants.

BACKGROUND: Despite a high prevalence of antibiotic resistance in Cambodia, few studies have assessed health-seeking behaviour and the use of antibiotics by caregivers of young children in Cambodia. METHODS: We conducted a cross-sectional survey of infants <12 months of age and their caregivers, assessing the frequency of reported illness, common symptoms and associated health-seeking behaviour through structured questionnaires administered by trained fieldworkers at a home visit. In a subset of these participants, ages 4-8 months with no acute malnutrition, we conducted a 3-month surveillance with fortnightly home visits. RESULTS: Of 149 infants (ages 1-11 months, 54.4% male) enrolled in the cross-sectional study, 76 (51.4%) reported symptoms of diarrhoea, fever or cough in the previous 14 d, with associated use of antibiotics reported in 22 (14.8%) infants. In 47 infants enrolled in the longitudinal surveillance, there were 141 reported episodes of illness in 44 (94%) infants with 21 infants (45%) reported to have received antibiotics in 32/141 (22.7%) episodes. Amoxicillin was the most commonly reported antibiotic in both surveys (68% [40/59 episodes reporting the use of antibiotics]). CONCLUSIONS: Antibiotic usage is high in this population and appears to be occurring largely outside of the formal healthcare system.

Perspectives of health care workers and village health volunteers on community-based Integrated Management of Childhood Illness in Madagascar.

The Ministry of Health and Family Planning of Madagascar introduced Integrated Management of Childhood Illness (IMCI) strategy in 2006, and community-based IMCI (c-IMCI), in Mahajanga II District in 2007. Following the 2009 political crisis, foreign organisations' suspension of development aid until 2012 significantly affected the implementation of c-IMCI. This study aimed to elucidate the perspectives of village health volunteers (VHVs) and public health officers (PHO) on c-IMCI. Semi-structured in-depth interviews with all VHVs working in three communes and PHOs working at central, district, and health centre levels were conducted in 2013. Textual data, created from transcripts, were translated into English and French. Data management involved analysis of sections of translated transcripts, which were marked, coded, and linked with similar experiences, challenges, and opinions; these were categorised into words and phrases to discover meaningful relationships between emerging themes. From all interviews of 30 VHV in three Mahajanga II communes and 4 PHOs, 3 themes emerged: 1) benefits of c-IMCI to the community and for VHVs, 2) challenges to continue c-IMCI, and 3) motivation to continue c-IMCI. Although all respondents considered c-IMCI as beneficial, they stated it was difficult to continue. The health system and implementation of c-IMCI should be strengthened to enable programme survival beyond the initial phase, especially during times of political instability.

Satisfaction of Pregnant Women with Antenatal Care Services at Women and Children Hospital in South Okkalapa, Myanmar: A Facility-Based Cross-Sectional Study Triangulated with Qualitative Study.

BACKGROUND: While patients' satisfaction is a barometer for healthcare quality, Myanmar did not do enough to assess the antenatal care (ANC) satisfaction. OBJECTIVE: In this study, we aim to assess the satisfaction level of pregnant women with ANC services provided by a public hospital in Myanmar. METHODS: A cross-sectional study was conducted with 125 women in the quantitative and 27 in the qualitative study at South Okkalapa Women and Children Hospital in Myanmar. Satisfaction was measured by using a five-point Likert scale with 25-item services. Statistical software SPSS version 16 was used for quantitative data analysis. Qualitative data were manually analyzed by thematic analysis. RESULTS: The proportion of pregnant women who were satisfied with healthcare services ranged from 18% to 35%. Provider's service yielded satisfaction ranging between 25% and 35%; meanwhile, facilities in the waiting area had the lowest mean score (2.78) for satisfaction. Laboratory service and waiting time at the antenatal clinic were major sources of dissatisfaction. Overall, 48% of the pregnant women were in high satisfaction with ANC services. Out of 25 items, cleanliness of ANC clinic, the process of ANC procedure, drug supply by the hospital, ventilation, and lighting in the waiting area, waiting time to see doctors, and working hours (availability of services) showed significant association with overall satisfaction. CONCLUSION: Nearly half of the pregnant women in the study were very satisfied with the total healthcare services they received. Facilities in the waiting area, laboratory service, and waiting time to see doctors were dissatisfied services and need to be upgraded.

Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has substantially impacted maternity care provision worldwide. Studies based on modelling estimated large indirect effects of the pandemic on services and health outcomes. The objective of this study was to prospectively document experiences of frontline maternal and newborn healthcare providers. METHODS: We conducted a global, cross-sectional study of maternal and newborn health professionals via an online survey disseminated through professional networks and social media in 12 languages. Information was collected between 24 March and 10 April 2020 on respondents' background, preparedness for and response to COVID-19 and their experience during the pandemic. An optional module sought information on adaptations to 17 care processes. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregating by low-income and middle-income countries (LMICs) and high-income countries (HICs). RESULTS: We analysed responses from 714 maternal and newborn health professionals. Only one-third received training on COVID-19 from their health facility and nearly all searched for information themselves. Half of respondents in LMICs received updated guidelines for care provision compared with 82% in HICs. Overall, 47% of participants in LMICs and 69% in HICs felt mostly or completely knowledgeable in how to care for COVID-19 maternity patients. Facility-level responses to COVID-19 (signage, screening, testing and isolation rooms) were more common in HICs than LMICs. Globally, 90% of respondents reported somewhat or substantially higher levels of stress. There was a widespread perception of reduced use of routine maternity care services, and of modification in care processes, some of which were not evidence-based practices. CONCLUSIONS: Substantial knowledge gaps exist in guidance on management of maternity cases with or without COVID-19. Formal information-sharing channels for providers must be established and mental health support provided. Surveys of maternity care providers can help track the situation, capture innovations and support rapid development of effective responses.

Prevalence of Perineal Lacerations in Women Giving Birth at Midwife-Led Birth Centers in Japan: A Retrospective Descriptive Study.

INTRODUCTION: Perineal lacerations during birth can cause ongoing physical, psychological, and social problems. However, the prevalence of lacerations following normal spontaneous vaginal birth in women with low-risk pregnancies is unknown. We investigated the prevalence of perineal lacerations and factors associated with lacerations among low-risk Japanese women who had normal spontaneous vaginal births. METHODS: Pregnant women who were cared for between January 1, 2008, and June 30, 2011, in 3 midwife-led birth centers in Tokyo, Japan, where invasive medical interventions are rarely applied, were included. We investigated the prevalence of perineal lacerations and conducted univariate and multivariate analyses on the relationship between the prevalence of lacerations and selected maternal and neonatal characteristics. RESULTS: A total of 1881 pregnant women had initial antenatal care at one of the 3 study sites. Of these, 1521 were eligible for inclusion. Intact perineum rates were 49.5% (209/422) and 69.9% (768/1099) in nulliparous and multiparous women, respectively. First-degree lacerations occurred in 36.7% (155/422) of nulliparous women and 27.1% (298/1099) of multiparous women, and second-degree lacerations occurred in 13.5% (57/422) of nulliparous women and 3.0% (33/1099) of multiparous women. One multiparous woman experienced a third-degree laceration (0.1%). No women suffered fourth-degree or cervical lacerations. Logistic regression analyses showed that older age (≥ 35 years), the hands-and-knees position, and using a birthing chair during birth increased the risk of perineal laceration both in nulliparous and in multiparous women. In addition, waterbirths increased the risk of perineal laceration in multiparous women. DISCUSSION: In normal spontaneous vaginal births among a low-risk population, it is possible to avoid episiotomy and achieve a high rate of intact perineum, with few second-degree and third-degree lacerations.