Trends in birth attendants in Sudan using three consecutive household surveys (from 2006 to 2014).

Introduction: Improving maternal health and survival remains a public health priority for Sudan. Significant investments were made to expand access to maternal health services, such as through the training and deployment of providers with varying skills and competencies to work across the country. This study investigates trends in the coverage of different birth attendants and their relationship with the maternal mortality ratio (MMR). Methods: Trend analyses were conducted using data from the 2006, 2010, and 2014 Sudan Household surveys. Three categories of birth attendants were identified: (1) skilled birth attendants (SBA) such as doctors, nurse-midwives, and health visitors, (2) locally certified midwives, and (3) traditional birth attendants (TBA). Multivariable logistic regression models were used to examine trends in SBAs (vs. locally certified midwives and TBAs), locally certified midwives (vs SBAs and TBAs), and SBAs and locally certified midwives by place of birth (health facility and home). The analyses were adjusted for potential confounders. An ecological analysis was conducted to assess the relationship between birth attendants by place of birth and MMR at the state level. Results: Births by 15,848 women were analysed. Locally certified midwives attended most births in each survey year, with their contribution increasing from 36.3% in 2006 to 55.5% in 2014. The contributions of SBAs and TBAs decreased over the same period. In 2014 compared with 2006, births were more likely to be attended by a locally certified midwife (aOR: 2.19; 95%CI: 1.82-2.63) but less likely to be attended by a SBA (aOR: 0.46; 95%CI: 0.37-0.56). The decrease in SBA was more substantial for births taking place at home (aOR: 0.17; 95%CI: 0.12-0.23) than for health facility births (aOR: 0.45; 95%CI: 0.31-0.65). In the ecological analysis 2014-2016, the proportion of births attended by SBA in health facilities correlated negatively with MMR at state level (rho -0.55; p: 0.02). Conclusion: This analysis suggests that although an improved coverage of maternal health with locally certified midwives has been observed, it has not provided the skill level reached by SBA. SBAs working in facility settings were a key correlating factor to reduced maternal mortality. Urgent action is needed to improve access to SBAs in health facilities, thereby accelerating progress in reducing maternal mortality.

Early management of meconium ileus in infants with cystic fibrosis: A prospective population cohort study.

BACKGROUND: Contemporary early outcome data of meconium Ileus (MI) in cystic fibrosis (CF) are lacking on a population level. We describe these and explore factors associated with successful non-operative management. METHODS: A prospective population-cohort study using an established surveillance system (BAPS-CASS) was conducted October 2012-September 2014. Live-born infants with bowel-obstruction from inspissated meconium in the terminal ileum and CF were reported. Data are described as median (interquartile range, IQR). RESULTS: 56 infants were identified. 14/56(25%) had primary laparotomy (13/23 complicated MI, 1/33 simple), the remainder underwent contrast enema. Twelve, (12/33 (36%) with simple MI) achieved decompression. 8/12 (67%) who decompressed had >1 enema vs 3/20 (15%) with simple MI who had laparotomy after enema. The number of enemas per infant (1-4), contrast agents and their concentration, were highly variable. Enterostomy was formed at 24/44(55%) of laparotomies. In infants with simple MI, time to full enteral feeds was 6 (2-10) days in those decompressing with enema vs 15 (9-19) days with laparotomy after enema. Case fatality was 4% (95% CI 0.4-12%). Two infants, both preterm died, both in the second month after birth. CONCLUSIONS: Infants with simple MI achieving successful enema decompression were more likely to have had repeat enemas than those who proceeded to laparotomy. Successful non-operative management was associated with a shorter time to full feeds. The early management of infants with MI is highly variable and not standardised across the UK and Ireland.

Neonatal admission and mortality in babies born in UK alongside midwifery units: a national population-based case-control study using the UK Midwifery Study System (UKMidSS).

OBJECTIVES: To determine the incidence of and risk factors for neonatal unit admission, intrapartum stillbirth or neonatal death without admission, and describe outcomes, in babies born in an alongside midwifery unit (AMU). DESIGN: National population-based case-control study. METHOD: We used the UK Midwifery Study System to identify and collect data about 1041 women who gave birth in AMUs, March 2017 to February 2018, whose babies were admitted to a neonatal unit or died (cases) and 1984 controls from the same AMUs. We used multivariable logistic regression, generating adjusted OR (aOR) with 95% CIs, to investigate maternal and intrapartum factors associated with neonatal admission or mortality. RESULTS: The incidence of neonatal admission or mortality following birth in an AMU was 1.2%, comprising neonatal admission (1.2%) and mortality (0.01%). White 'other' ethnicity (aOR=1.28; 95% CI=1.01 to 1.63); nulliparity (aOR=2.09; 95% CI=1.78 to 2.45); ≥2 previous pregnancies ≥24 weeks' gestation (aOR=1.38; 95% CI=1.10 to 1.74); male sex (aOR=1.46; 95% CI=1.23 to 1.75); maternal pregnancy problem (aOR=1.40; 95% CI=1.03 to 1.90); prolonged (aOR=1.42; 95% CI=1.01 to 2.01) or unrecorded (aOR=1.38; 95% CI=1.05 to 1.81) second stage duration; opiate use (aOR=1.31; 95% CI=1.02 to 1.68); shoulder dystocia (aOR=5.06; 95% CI=3.00 to 8.52); birth weight <2500 g (aOR=4.12; 95% CI=1.97 to 8.60), 4000-4999 g (aOR=1.64; 95% CI=1.25 to 2.14) and ≥4500 g (aOR=2.10; 95% CI=1.17 to 3.76), were independently associated with neonatal admission or mortality. Among babies admitted (n=1038), 18% received intensive care. Nine babies died, six following neonatal admission. Sepsis (52%) and respiratory distress (42%) were the most common discharge diagnoses. CONCLUSIONS: The results of this study are in line with other evidence on risk factors for neonatal admission, and reassuring in terms of the quality and safety of care in AMUs.

Each baby counts: National quality improvement programme to reduce intrapartum-related deaths and brain injuries in term babies.

Although the most recent MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) perinatal mortality report has shown a downward trend in perinatal mortality, the UK still lags behind the best-performing countries in Europe. The burden of perinatal morbidity and mortality is wide-reaching and devastating for the families and care-providers involved. The aim of the Each Baby Counts (EBC) project is to reduce intrapartum term stillbirths, early neonatal deaths, and severe brain injuries by 50% by 2020. Every maternity care provider has been asked to report their intrapartum term stillbirths, early neonatal deaths and severe brain injuries to the EBC project and provide a copy of the local review. The local reviews are assessed by two trained EBC reviewers in order to establish whether the reviews are of adequate quality. The EBC reviewers are asked independently to assess whether there is sufficient clinical information to make a clinical judgement about care, and whether different care could have had a positive impact on the outcome. The reviewers are asked to indicate in what areas care might be improved. The analysis of the local reports will be twofold. Initially quantitative analysis will provide us with information about the scale of the problem, the quality of the local review process into adverse events, and who is involved in such reviews. Qualitative analysis of the themes highlighted in the reviews will enable us to develop care bundles or other tools to drive local quality improvement.

The UK Midwifery Study System (UKMidSS): a programme of work to establish a research infrastructure to carry out national studies of uncommon conditions and events in midwifery units.

BACKGROUND: Midwifery-led care during labour and birth in the UK is increasingly important given national commitments to choice of place of birth, reduction of unnecessary intervention and improving women's experience of care, and evidence on safety and benefits for 'low risk' women. Further evidence is needed on safety and potential benefits of midwifery-led care for some groups of 'higher risk' women and about uncommon adverse outcomes or 'near-miss' events. Uncommon obstetric events and conditions have been investigated since 2005 using the UK Obstetric Surveillance System. This programme of research will establish the UK Midwifery Study System (UKMidSS) in all UK alongside midwifery units (AMUs) and carry out the first two UKMidSS studies investigating: (i) outcomes in severely obese women admitted to AMUs, and (ii) risk factors for neonatal unit admission following birth in an AMU. METHODS: We will carry out national cohort and case-control studies using UKMidSS, a national data collection platform which we will establish to collect anonymised information from all UK AMUs. Reporting midwives in each AMU will actively report cases or nil returns in response to monthly notification emails. Denominator data on the number of women admitted to and giving birth in each AMU will also be collected. Anonymised data on risk factors, management and outcomes for cases and controls/comparators as appropriate for each study, will be collected electronically using information from medical records. We will calculate incidence and prevalence with 95% confidence intervals (CIs), tabulate descriptive data using frequencies and proportions, and use logistic regression to estimate odds ratios with 95% CIs comparing specific outcomes in case and comparison women and to investigate risk factors for conditions or outcomes. DISCUSSION: As the first national infrastructure facilitating research into uncommon events and conditions in women starting labour in midwifery-led settings, UKMidSS builds on the success of other national research systems. UKMidSS studies will extend the evidence base regarding the quality and safety of midwifery-led intrapartum care and investigate extending the benefits of midwifery-led care to more women. As a national collaboration of midwives contributing to high quality research, UKMidSS will provide an infrastructure to support midwifery research capacity development.

Duration and urgency of transfer in births planned at home and in freestanding midwifery units in England: secondary analysis of the birthplace national prospective cohort study.

BACKGROUND: In England, there is a policy of offering healthy women with straightforward pregnancies a choice of birth setting. Options may include home or a freestanding midwifery unit (FMU). Transfer rates from these settings are around 20%, and higher for nulliparous women. The duration of transfer is of interest because of the potential for delay in access to specialist care and is also of concern to women. We aimed to estimate the duration of transfer in births planned at home and in FMUs and explore the effects of distance and urgency on duration. METHODS: This was a secondary analysis of data collected in a national prospective cohort study including 27,842 'low risk' women with singleton, term, 'booked' pregnancies, planning birth in FMUs or at home in England from April 2008 to April 2010. We described transfer duration using the median and interquartile range, for all transfers and those for reasons defined as potentially urgent or non-urgent, and used cumulative distribution curves to compare transfer duration by urgency. We explored the effect of distance for transfers from FMUs and described outcomes in women giving birth within 60 minutes of transfer. RESULTS: The median overall transfer time, from decision to transfer to first OU assessment, was shorter in transfers from home compared with transfers from FMUs (49 vs 60 minutes; p < 0.001). The median duration of transfers before birth for potentially urgent reasons (home 42 minutes, FMU 50 minutes) was 8-10 minutes shorter compared with transfers for non-urgent reasons. In transfers for potentially urgent reasons, the median overall transfer time from FMUs within 20 km of an OU was 47 minutes, increasing to 55 minutes from FMUs 20-40 km away and 61 minutes in more remote FMUs. In women who gave birth within 60 minutes after transfer, adverse neonatal outcomes occurred in 1-2% of transfers. CONCLUSIONS: Transfers from home or FMU commonly take up to 60 minutes from decision to transfer, to first assessment in an OU, even for transfers for potentially urgent reasons. Most transfers are not urgent and emergencies and adverse outcomes are uncommon, but urgent transfer is more likely for nulliparous women.

Origins of magic: review of genetic and epigenetic effects.

OBJECTIVE: To assess the evidence for a genetic basis to magic. DESIGN: Literature review. SETTING: Harry Potter novels of J K Rowling. PARTICIPANTS: Muggles, witches, wizards, and squibs. INTERVENTIONS: Limited. MAIN OUTCOME MEASURES: Family and twin studies, magical ability, and specific magical skills. RESULTS: Magic shows strong evidence of heritability, with familial aggregation and concordance in twins. Evidence suggests magical ability to be a quantitative trait. Specific magical skills, notably being able to speak to snakes, predict the future, and change hair colour, all seem heritable. CONCLUSIONS: A multilocus model with a dominant gene for magic might exist, controlled epistatically by one or more loci, possibly recessive in nature. Magical enhancers regulating gene expressionmay be involved, combined with mutations at specific genes implicated in speech and hair colour such as FOXP2 and MCR1.