The magnitude and associated factors of immediate postpartum anemia among women who gave birth in Ethiopia: systematic review and meta-analysis, 2023.

BACKGROUND: The immediate postpartum period is a very crucial phase for both the life of the mother and her newborn baby. Anemia is the most indirect leading cause of maternal mortality. However, anemia in the immediate postpartum period is a neglected public health problem in Ethiopia. Therefore, this systematic review and meta-analysis aimed to estimate the pooled magnitude of immediate postpartum anemia and the pooled effect size of associated factors in Ethiopia. METHODS: Searching of published studies done through PubMed, Medline, Cochrane, African index Medicus, List of Reference Index, Hinari, and Google Scholar. This systematic review and meta-analysis follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) godliness. The quality of studies was assessed by using a Newcastle- Ottawa Scale (NOS) assessment tool. Analysis was performed using a random effect model by using STATA 17 version software. Egger's weighted regression and I2 test were used to evaluate publication bias and heterogeneity respectively. RESULTS: In this systematic review and meta-analysis, a total of 6 studies were included. The pooled magnitude of immediate postpartum anemia in Ethiopia was 27% (95%CI: 22, 32). Instrumental mode of delivery (OR = 3.14, 95%CI: 2.03, 4.24), mid-upper arm circumference (MUAC) measurement < 23 cm (OR = 3.19, 95%CI: 1.35, 5.03), Antepartum Hemorrhage (OR = 4.75, 95%CI: 2.46, 7.03), postpartum hemorrhage (OR = 4.67, 95%CI: 2.80, 6.55), and no iron/foliate supplementation (OR = 2.72, 95%CI: 1.85, 3.60) were the identified factors associated with developing anemia in the immediate postpartum period. CONCLUSION: The overall pooled magnitude of anemia in the immediate postpartum period among Ethiopian women was still a moderate public health problem. Instrumental mode of delivery, mid upper arm circumference (MUAC) measurement < 23 cm, antepartum hemorrhage, postpartum hemorrhage, and no iron/foliate supplementation were the identified factors associated with higher odds of developing anemia among immediate postpartum women in Ethiopia. Therefore, midwives, and doctors, shall focus on prevention of maternal hemorrhage, nutritional advice and counseling including iron /foliate supplementation, and avoid unnecessary instrumental delivery to prevent and reduce anemia related maternal mortality and morbidity in Ethiopia. PROSPERO REGISTRATION: CRD42023437414 with registration date on 02/08/2023.

Characteristics and treatment for severe postpartum haemorrhage in different midwifery hospitals in one district of Beijing in China: an institution-based, retrospective cohort study.

OBJECTIVE: To identify the characteristics and treatment approaches for patients with severe postpartum haemorrhage (SPPH) in various midwifery institutions in one district in Beijing, especially those without identifiable antenatal PPH high-risk factors, to improve regional SPPH rescue capacity. DESIGN: Retrospective cohort study. SETTING: This study was conducted at 9 tertiary-level hospitals and 10 secondary-level hospitals in Haidian district of Beijing from January 2019 to December 2022. PARTICIPANTS: The major inclusion criterion was SPPH with blood loss ≥1500 mL or needing a packed blood product transfusion ≥1000 mL within 24 hours after birth. A total of 324 mothers with SPPH were reported to the Regional Obstetric Quality Control Office from 19 midwifery hospitals. OUTCOME MEASURES: The pregnancy characteristics collected included age at delivery, gestational weeks at delivery, height, parity, delivery mode, antenatal PPH high-risk factors, aetiology of PPH, bleeding amount, PPH complications, transfusion volume and PPH management. SPPH characteristics were compared between two levels of midwifery hospitals and their association with antenatal PPH high-risk factors was determined. RESULTS: SPPH was observed in 324 mothers out of 106 697 mothers in the 4 years. There were 74.4% and 23.9% cases of SPPH without detectable antenatal PPH high-risk factors in secondary and tertiary midwifery hospitals, respectively. Primary uterine atony was the leading cause of SPPH in secondary midwifery hospitals, whereas placental-associated disorders were the leading causes in tertiary institutions. Rates of red blood cell transfusion over 10 units, unscheduled returns to the operating room and adverse PPH complications were higher in patients without antenatal PPH high-risk factors. Secondary hospitals had significantly higher rates of trauma compared with tertiary institutions. CONCLUSION: Examining SPPH cases at various institutional levels offers a more comprehensive view of regional SPPH management and enhances targeted training in this area.

Prepartum Anemia and Risk of Postpartum Hemorrhage: A Meta-Analysis and Brief Review.

Postpartum hemorrhage (PPH) is responsible for 30% to 50% of maternal deaths. There is conflicting evidence if prepartum anemia facilitates PPH. A comprehensive analysis of studies describing their relation is missing. An extensive database search was conducted applying the terms "anemia" OR "hemoglobin" AND "postpartum hemorrhage." We used a random-effects meta-analysis model to estimate an overall odds ratio (OR) for PPH and prepartum anemia, separating studies that were conformant and non-conformant with the World Health Organization (WHO) definitions for anemia. The search yielded 2519 studies, and 46 were appropriate for analysis. The meta-analyses of WHO-conformant (n = 22) and non-conformant (n = 24) studies showed that the risk of PPH was increased when anemia was present. The ORs were 1.45 (CL: 1.23-1.71) for WHO-conformant studies, 2.88 (CL: 1.38-6.02) for studies applying lower thresholds for anemia, and 3.28 (CL: 2.08-5.19) for undefined anemia thresholds. PPH risk appeared to increase with lower anemia thresholds. Prepartum anemia is associated with an increased risk of PPH, an observation that is important regarding improved anemia correction strategies such as iron supplementation.

Postpartum haemorrhage occurring in UK midwifery units: A national population-based case-control study to investigate incidence, risk factors and outcomes.

OBJECTIVES: To estimate the incidence of, and investigate risk factors for, postpartum haemorrhage (PPH) requiring transfer to obstetric care following birth in midwifery units (MU) in the UK; to describe outcomes for women who experience PPH requiring transfer to obstetric care. METHODS: We conducted a national population-based case-control study in all MUs in the UK using the UK Midwifery Study System (UKMidSS). Between September 2019 and February 2020, 1501 women with PPH requiring transfer to obstetric care following birth in an MU, and 1475 control women were identified. We used multivariable logistic regression, generating adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to investigate risk factors for PPH requiring transfer to obstetric care. RESULTS: The incidence of PPH requiring transfer to obstetric care following birth in an MU was 3.7% (95% CI 3.6%-3.9%). Factors independently associated with PPH requiring transfer to obstetric care were smoking during pregnancy (aOR = 0.73; 95% CI 0.56-0.94), nulliparity (aOR = 1.96; 95% CI 1.66-2.30), previous PPH (aOR = 2.67; 95% CI 1.67-4.25), complications in a previous pregnancy other than PPH (aOR = 2.40; 95% CI 1.25-4.60), gestational age ≥41 weeks (aOR = 1.36; 95% CI 1.10-1.69), instrumental birth (aOR = 2.69; 95% CI 1.53-4.72), third stage of labour ≥60 minutes (aOR = 5.56; 95% CI 3.93-7.88), perineal trauma (aOR = 4.67; 95% CI 3.16-6.90), and birthweight 3500-3999g (aOR = 1.71; 95% CI 1.42-2.07) or ≥4000g (aOR = 2.31; 95% CI 1.78-3.00). One in ten (10.6%) cases received a blood transfusion and one in five (21.0%) were admitted to higher level care. CONCLUSIONS: The risk factors identified in this study align with those identified in previous research and with current guidelines for women planning birth in an MU in the UK. Maternal outcomes after PPH were broadly reassuring and indicative of appropriate management. NHS organisations should ensure that robust guidelines are in place to support management of PPH in MUs.

Establishment and Validation of Risk Prediction Model for Postpartum Hemorrhage for Pregnant Women ≥35 Years of Age in Natural Delivery.

Context: After the age of 35, women's fertility and physical function gradually decline, and this can significantly increase the risks of postpartum hemorrhage (PPH) after delivery. Sufficient exploration of prenatal indicators of PPH for older pregnant women are still lacking. Objective: The study intended to examine the factors influencing postpartum hemorrhage (PPH) in natural delivery for pregnant women ≥35 years of age and to establish a reliable risk-prediction model. Design: The research team performed a retrospective study. Setting: The study took place at Suzhou Ninth People's Hospital in Suzhou, Jiangsu Province, China. Participants: Participants were 351 pregnant women who had undergone a prenatal examination and vaginal delivery at the hospital between January 2019 and October 2022. Groups: The research team divided participants into two groups: (1) a PPH group, with 52 participants who experienced PPH, and (2) a non-PPH group, with 299 participants who had no PPH. Outcome Measures: The research team: (1) conducted single-factor analysis of the two groups' demographic and clinical characteristics; (2) performed multivariate logistic regression analysis to find the factors influencing PPH; (3) built a risk-prediction model based on the results; and (4) analyzed the model's identification ability, proofreading ability, and clinical applicability using a goodness-of-fit test, a receiver operating characteristic (ROC) curve, a calibration curve, and a decision curve. The team used the SPSS 22.0 and R software for statistical analysis. Results: The incidence of PPH was 14.81%, for the 52 out of 351 participants. The PPH group's age (P < .001), rate of pregnancy-induced hypertension (P = .008), length of the third stage of labor (P = .001), and newborn's birth weight (P < .001) were significantly greater and its FIB before delivery was significantly lower than those of the non-PPH group. The high expression of fibrinogen (FIB) before delivery indicates it may be a protective factor against PPH. The multivariate analysis indicated that a greater age (P = .013), pregnancy-induced hypertension (P = .002), a low FIB level (P < .001), a long third stage of labor (P = .012), and a low birth weight for the newborn (P = .006) were all significantly related to PPH. The research team validated the risk-prediction model, which indicated that the model had good recognition ability (AUC = 0.873). The optimal critical value was 34%, and the sensitivity and specificity were 0.869 and 0.826, respectively. In the comparison of the PPH value that the model predicted and the participants' actual PPH incidence (U = -0.006, Brier = 0.089), the deviation of the model wasn't statistically significant (χ2 = 5.964, P = .651). The analysis of the decision curve found that the net benefits for pregnant women ≥35 years of age were higher than those of the other two extreme curves, showing that the model was clinically effective. Conclusions: The PPH risk-prediction model for vaginal delivery for pregnant women ≥35 years of age showed that a greater age, pregnancy-induced hypertension, a lower prelabor FIB, a longer third stage of labor, and a higher birth weight for the newborn were significantly related to the incidence of PPH and that its use could be clinically helpful.

Traditional birth attendants' knowledge, preventive and management practices for postpartum haemorrhage in Osun State, Southwestern Nigeria.

Traditional birth attendants (TBAs) have become an integral part of the workforce providing delivery services in Nigeria due to the limited number of skilled birth attendants and cultural preferences. This study assessed the knowledge, management and preventive practices regarding postpartum haemorrhage (PPH) among TBAs in selected communities in Osun State, Southwest Nigeria. The study employed a descriptive cross-sectional study design and recruited 260 TBAs in four communities in Osun State. Data were collected by means of an adapted semi-structured questionnaire. Data were analysed using SPSS version 23 and summarized using descriptive and inferential statistics (chi-square and logistic regression) with the level of significance set at p < 0.05. The findings indicated that most (71.4%) of the TBAs were cleric, while others were herbalist (28.6%). Although the majority (76.4%) of the TBAs had good knowledge of the causes and warning signs of PPH, a high percentage (69.3%) of TBAs had poor management practices, while 114 (64.1%) TBAs had inadequate preventive practices. Notably, almost none of the participants practised active management of the third stage of labour; the majority of TBAs did not administer any uterotonic drugs to the mother, nor did they deliver the placenta by controlled cord traction. Gender (P = 0.029), educational level (P = 0.035) and average number of births per month (P = 0.001) significantly influenced TBAs' management practices. Similarly, the TBA type (P < 0.001), average number of births per month (P = 0.003) and experience with formal training (P = 0.005) showed significant associations with TBAs' preventive practices. Furthermore, TBAs' preventive practices towards PPH were influenced by the TBA type (OR: 4.23; 95% CI 1.64-10.90). TBA management practices were also influenced by the TBA type (OR: 4.42; 95% CI 2.03-9.61). Traditional birth attendants in this study had poor management and poor preventive practices for postpartum haemorrhage.

Outcomes for women admitted for labour care to alongside midwifery units in the UK following a postpartum haemorrhage in a previous pregnancy: A national population-based cohort and nested case-control study using the UK Midwifery Study System (UKMidSS).

BACKGROUND: Women who have experienced a postpartum haemorrhage (PPH) 'requiring treatment or transfusion' are typically advised to plan birth in obstetric-led settings in subsequent pregnancies. Many UK alongside midwifery units (AMU) admit women for labour care following a previous PPH. We aimed to describe outcomes in women admitted for labour care to AMUs following a previous PPH, compare outcomes with other multiparous women admitted to the same AMUs, and explore risk factors for recurrence. METHODS: A national cohort and nested case-control study using the UK Midwifery Study System (UKMidSS), between August 2018 and April 2019. Multivariable Poisson regression and logistic regression were performed to compare outcomes and investigate risk factors for recurrence. FINDINGS: Women who experienced a previous PPH were significantly more likely than comparison women to: have a PPH requiring transfer to obstetric care (4·2% vs. 2·4%, aRR=1·65, 95% CI 1·14-2·38), be transferred to obstetric care for any reason (17·8% vs 11·9%; aRR=1·41; 95% CI 1·09-1·83), and have any PPH≥ 500 ml (22·7% vs 11·1%, aRR=1·86, 95% CI 1·49-2·32). Among women with a previous PPH, previous blood loss > 1500 ml; uterotonics for previous PPH; Caesarean associated with previous PPH; gestation at admission and higher birthweight were independent risk factors for PPH. CONCLUSION: Women considering birth in an AMU after a previous PPH should be advised that they are at increased risk of experiencing a subsequent PPH requiring transfer to obstetric care, compared with other multiparous women who have not had a PPH. The absolute risk of a subsequent PPH in this group is low and comparable to the overall risk of having a PPH among women having a spontaneous vaginal birth in England.

Recognizing who is at risk for postpartum hemorrhage: targeting anemic women and scoring systems for clinical use.

Iron deficiency anemia during pregnancy is a common concern, affecting 38% of women worldwide and up to 50% in developing countries. It is defined differently throughout all 3 trimesters. It has several detrimental effects on pregnancy outcomes for both the mother and the fetus, such as increasing the risk for postpartum depression, preterm delivery, cesarean delivery, preeclampsia, and low birthweight. Management of iron deficiency anemia is done classically via oral iron supplementation. However, recent evidence has shown that intravenous iron is a good alternative to oral iron if patients are unable to tolerate it, not responding, or present with a new diagnosis very late in pregnancy. Management of iron deficiency anemia was demonstrated to be protective against postpartum hemorrhage. Other ways to prevent postpartum hemorrhage include improving prediction tools that can identify those at risk. Several risk assessment kits have been developed to estimate the risk for postpartum hemorrhage among patients and have been proven useful in the prediction of patients at high risk for postpartum hemorrhage despite limitations among low-risk groups. More comprehensive tools are also being explored by determining clinically relevant factors through nomograms, with some proving their efficacy after implementation. Machine learning is also being used to develop more complete tools by including risk factors previously not accounted for. These newer tools, however, still require external validation before being adopted despite promising results under testing conditions.

Effect of Predictive Nursing Combined with Early Drinking Water Therapy on Patients with Urinary Retention after Vaginal Delivery.

The aim of this study is to analyze the effect of predictive nursing combined with early drinking water therapy on patients with urinary retention after vaginal delivery. A total of 600 women who gave birth in our hospital from July 2019 to July 2020 were selected as the research objects. A double-blind method was adopted to divide them into a control group and observation group, 300 cases in each group. In the control group, routine nursing was given. In the observation group, (1) predictive nursing measures were used before surgery. (2) The postoperative observation group used early drinking water therapy; the incidence of urinary retention, the effective rate of urination, postpartum haemorrhage, and the treatment of urinary retention were compared between the two groups. In the observation group, the number of urinary retention was 17, and the incidence of urinary retention was 5.67%. The urination efficiency of the observation group was 98.33%; the urination efficiency of the control group was 86.33%; comparison results showed that P < 0.05. The 24 h postpartum haemorrhage of the observation group was 1.33%; the 24 h postpartum haemorrhage of the control group was 2.66%. Uroschesis therapy was performed in 17 patients in the observation group and 44 patients in the control group.. The observation group had an 88.24 percent treatment rate, while the control group had a 72.73 percent treatment rate. P < 0.05 indicated that the difference was statistically significant.

Low Maternal Serum 25-Hydroxyvitamin D Concentration Is Associated With Postpartum Hemorrhage: A Retrospective Observational Study.

Objective: The primary aim of this study is to investigate the relationship between vitamin D serum level and the incidence of postpartum hemorrhage (PPH). The secondary objective is to determine the relative risk of low vitamin D associated with PPH. Methods: This was a retrospective observational study. A total of 600 women who had delivered their babies in a single tertiary teaching hospital were enrolled. Serum blood test for 25(OH)D was performed at 35 + 0 to 36 + 6 weeks of pregnancy to measure vitamin D. A 25(OH)D level < 20 ng/mL was defined as vitamin D deficient, and a level 21-29 ng/mL as insufficient. Results: Vitamin D levels were deficient in 145 (24.1%) and insufficient in 254 (42.3%) of the women tested. Women with deficient and insufficient vitamin D levels were significantly younger than those with sufficient vitamin D levels (p < 0.001). The overall rates of PPH in the deficient and insufficient groups were 6.9% (10/145) and 6.7% (17/254), respectively, and were significantly higher than the rate of the normal vitamin D group (1.5%, p = 0.009). Women with sufficient vitamin D levels had significantly higher hemoglobin levels than those with low vitamin D levels. Higher vitamin D levels were associated with a significantly low risk of PPH (AOR: 0.93, CI: 0.89-0.98, p = 0.006). Conclusion: Our results suggest that a low vitamin D level is a risk factor for PPH. Low vitamin D also related to high risk of low hemoglobin before delivery. Thus, antepartum care should include vitamin D supplements for all women if possible.

Management and outcomes of mild hemophiliacs and hemophilia carriers during pregnancy and peripartum period: a hemophilia treatment center experience in the United States.

BACKGROUND: Pregnancy, peripartum management, and outcomes of mild hemophiliacs and hemophilia carriers in the United States are not well established. AIM: To describe the management and outcomes of mild hemophiliacs and hemophilia carriers during assisted conception, pregnancy, peripartum and post-partum period at our hemophilia treatment center (HTC). METHODS: Retrospective review of electronic medical records of pregnant women with mild hemophilia A or B (Factor VIII [FVIII] or Factor IX [FIX] level <0.4 IU/mL) and hemophilia A and B carriers followed at our HTC from January 2008 to October 2020. Demographics, the reason for diagnosis, FVIII and FIX levels at baseline and third trimester, bleeding phenotype and genotype were obtained. Method of conception, factor replacement, iron supplementation, mode of delivery, type of anesthesia, peripartum complications, and offspring outcomes was recorded. RESULTS: There was a total of 18 pregnancies in 12 women (2 with mild hemophilia A, 2 mild hemophilia B, 6 hemophilia A carriers, and 2 hemophilia B carriers). Eleven pregnancies (61%) were conceived naturally and 7 (39%) via in-vitro fertilization (IVF). Eight (44.4%) and 10 (55.6%) pregnancies were vaginal and C-section deliveries, respectively. Neuraxial anesthesia was administered in 17 (94.4%) deliveries without complications. Four pregnancies (22.2%) had bleeding complications, 2 of which were post-partum hemorrhages not requiring transfusion. CONCLUSION: In our case series of pregnant hemophilia carriers and mild hemophiliacs, successful outcomes were achieved with a carefully detailed multidisciplinary-driven approach.

How do I perform cell salvage during vaginal obstetric hemorrhage?

BACKGROUND: Obstetric hemorrhage is a leading cause of preventable maternal mortality. To combat this, obstetric organizations worldwide recommend consideration of autotransfusion during severe peripartum bleeding to minimize allogenic transfusion. Current guidelines for autotransfusion in obstetrics are limited to patients undergoing cesarean birth. At present, women experiencing vaginal obstetric hemorrhage are excluded from many obstetric autotransfusion protocols. However, emerging data suggest that autotransfusion of vaginally shed blood is both safe and feasible in the obstetric patient population. METHODS AND MATERIALS: In this review, we will provide an overview of the current literature surrounding cell salvage of vaginally send blood and a detailed outline of our institution's blood collection protocol. RESULTS: Recent data suggests autotransfusion of vaginally shed blood is both safe and effective. DISCUSSION: Implementation of autotransfusion technology into the delivery room is a critical next step for the advancement of transfusion medicine in obstetrics. This review provides an overview of the data surrounding autotransfusion of vaginally shed blood during maternal hemorrhage and describes practical suggestions for how it can be effectively implemented into routine practice.

Postpartum hemorrhage: Moving from response to prevention for Alaska Native mothers.

OBJECTIVE: To identify risk factors for postpartum hemorrhage in a population of Alaska Native women. METHODS: A case-control study of 384 women (128 cases, 256 controls) delivering between August 1, 2018, and July 31, 2019, was conducted at a Level III maternal referral center for Alaska Native women in Alaska. Risk factors were assessed via retrospective chart review, and bivariate and conditional regression analyses were conducted to determine odds ratios (ORs) between women with and without postpartum hemorrhage. RESULTS: Body mass index ≥40 (OR 2.6, 95% confidence interval [CI] 1.4-4.5), antepartum bleeding (OR 6.3, 95% CI 1.2-31.6), previous postpartum hemorrhage (OR 5, 95% CI 2.6-9.8), suspected macrosomia (OR 2.7, 95% CI 1.4-5.3), macrosomia with birthweight ≥4000 g (OR 3.1, 95% CI 1.8-5.3), pre-eclampsia with magnesium sulfate (OR 4.0, 95% CI 2.0-8.0), length of third stage of labor >20 min (OR 2.2, 95% CI 1.1-4.4), oxytocin use >12 h (OR 5.4, 95% CI 2.0-14.6), residence in a rural community (OR 2.2, 95% CI 1.4-3.6), and vitamin D supplementation (OR 1.7, 95% CI 1.1-2.6) were associated with greater risk of postpartum hemorrhage. CONCLUSION: Analysis of clinical and geographic risk factors for postpartum hemorrhage in Alaska Native women identified important targets for prevention.

Uterine Massage to Reduce Blood Loss Before Delivery of the Placenta in Caesarean Section: A Retrospective Cohort Study.

BACKGROUND/OBJECTIVE: To estimate the effectiveness of uterine massage UM in reducing blood loss before delivery of placenta in CS. METHODS: This was a retrospective cohort study of 1393 women who delivered with CS. Patients who underwent UM (671women) were compared with those who underwent controlled cord traction (722 women). According to risk assessment of PPH, 2 groups were both divided to low risk group and high risk group. Outcomes included blood loss amount within 2 h after delivery, incidence of PPH and intractable PPH. RESULTS: Blood loss amount within 2 h was lower in UM group than CCT group(516.6±196.5 ml compared with 674.1±272.2 ml, P<0.01). The incidence of PPH and intractable PPH didn't differ significantly between the 2 groups (6.7% compared with 9.1%, P=0.09 and 3.9% compared with 5.3%, P=0.22,respectively).In high risk group, the amount of blood loss within 2 h and the incidence of PPH were both lower in UM group (n=382) than CCT group (n=407) (576.8±228.1 ml compared with 854.9±346.1 ml, P<0.01 and 7.1% compared with 11.3%,P=0.04 ,respectively). The incidence of intractable PPH didn't differ significantly between the 2 groups (4.7% compared with 6.9%,P=0.19). In low risk group, the 3 outcomes didn't differ significantly between the 2 groups(n=289 vs. 315) (428.5±172.6 ml compared with 447.9±180.5 ml; 6.2% compared with 6.3%; 2.8% compared with 3.2%; P=0.56, 0.95 and 0.77,respectively). CONCLUSION: In high risk patients of PPH, UM before delivery of placenta contributed to reduce blood loss in CS.

A review of postpartum hemorrhage in low-income countries and implications for strengthening health systems.

Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide. Disparities in PPH-associated survival between high and low-/middle-income countries reflect an imperative for low-resource countries to improve strategies for rapid diagnosis and treatment. A review of current PPH diagnosis, prevention, treatment, and access to care in low-income countries has been used to understand, extract, and report the challenges that public health systems face in trying to solve the marked global disparity in PPH outcomes. Improvement in PPH survival begins with holistic strengthening of each step along the continuum of care in health systems and should include performance feedback measures and quality-of-care research.

Birth Outcomes of Women with Obesity Enrolled for Care at Freestanding Birth Centers in the United States.

INTRODUCTION: Current US guidelines for the care of women with obesity generalize obesity-related risks to all women regardless of overall health status and assume that birth will occur in hospitals. Perinatal outcomes for women with obesity in US freestanding birth centers need documentation. METHODS: Pregnancies recorded in the American Association of Birth Centers Perinatal Data Registry were analyzed (n = 4,455) to form 2 groups of primiparous women (n = 964; 1:1 matching of women with normal body mass indices [BMIs] and women with obese BMIs [>30]), using propensity score matching to address the imbalance of potential confounders. Groups were compared on a range of outcomes. Differences between groups were evaluated using χ2 test for categorical variables and Student's t test for continuous variables. Paired t test and McNemar's test evaluated the differences among the matched pairs. RESULTS: The majority of women with obese BMIs experienced uncomplicated perinatal courses and vaginal births. There were no significant differences in antenatal complications, proportion of prolonged pregnancy, prolonged first and second stage labor, rupture of membranes longer than 24 hours, postpartum hemorrhage, or newborn outcomes between women with obese BMIs and normal BMIs. Among all women with intrapartum referrals or transfers (25.3%), the primary indications were prolonged first stage or second stage (55.4%), inadequate pain relief (14.8%), client choice or psychological issue (7.0%), and meconium (5.3%). Primiparous women with obesity who started labor at a birth center had a 30.7% transfer rate and an 11.1% cesarean birth rate. DISCUSSION: Women with obese BMIs without medical comorbidity can receive safe and effective midwifery care at freestanding birth centers while anticipating a low risk for cesarean birth. The risks of potential, obesity-related perinatal complications should be discussed with women when choosing place of birth; however, pregnancy complicated by obesity must be viewed holistically, not simply through the lens of obesity.

Effects of team-based learning about postpartum haemorrhage on learning outcomes and experience of midwifery students in Indonesia: A pilot study.

Aim: This pilot study aimed to evaluate the effects of team-based learning about postpartum haemorrhage on the learning outcomes and experience of midwifery students in Indonesia. Design: One-group pre-test-post-test study. Methods: This study enrolled 64 midwifery students as participants from an Indonesian health polytechnic school. This group attended two team-based learning class sessions (90 min weekly for 2 weeks) on postpartum haemorrhage. Student learning outcomes and experience were assessed quantitatively. Results: The mean knowledge score (0-100) was significantly higher at post-test (mean = 85.9, SD 9.8) than at pre-test (mean = 61.4, SD 12.9) (p < .001). There was a significant difference in the mean clinical reasoning score (12-60) between post-test (mean = 35.4, SD 5.8) and pre-test (mean = 21.3, SD 7.9) (p < .001). Most students (98.4%) engaged in classroom activities.

Factors affecting third-stage management and postpartum hemorrhage in planned midwife-led home and birth center births in the United States.

BACKGROUND: Postpartum hemorrhage (PPH) is a potential childbirth complication. Little is known about how third-stage labor is managed by midwives in the United States, including use of uterotonic medication during community birth. Access to uterotonic medication may vary based on credentials of the midwife or state regulations governing midwifery. METHODS: Using data from the Midwives of North America 2.0 database (2004-2009), we describe the PPH incidence for women giving birth in the community, their demographic and clinical characteristics, and methods used by midwives to address PPH. We also examined PPH rates by midwifery credentials and by the presence of regulations for legal midwifery practice. RESULTS: Of the 17 836 vaginal births, 15.9% had blood loss of over 500 mL and 3.3% had 1000 mL or greater blood loss. Midwives used pharmaceuticals to prevent or treat postpartum bleeding in 6.3% and 13.9% of births, respectively, and the rate of hospital transfer after birth was 1.4% (n = 247). In adjusted analyses, PPH was less likely when births occurred at home vs a birth center, if the midwife had a CNM/CM credential vs a CPM/LM/LDM credential, or if the woman was multiparous without a history of PPH or prior cesarean birth. PPH was more likely in states with barriers to midwifery practice compared with regulated states (OR: 1.26; 95% CI, 1.16-1.38). CONCLUSIONS: Women giving birth in the community experienced low overall incidence of PPH-related hospital transfer. However, the occurrence of PPH itself would likely be reduced with improved legal access to uterotonic medication.

Maternal and neonatal outcome of births planned in alongside midwifery units: a cohort study from a tertiary center in Germany.

BACKGROUND: For healthy women entering birth after uneventful pregnancy, midwife-led models of care have the potential to reduce interventions and increase the vaginal birth rate. In Germany, 98.4% of women are giving birth in consultant-led obstetric units. Alongside midwifery units (AMU) have been established in 2003. We compared the outcome of women registered for planned birth in the AMU at our hospital with a matched group of low-risk women who gave birth in standard obstetric care during the same period of time. METHODS: We used a retrospective cohort study design. The study group consisted of all women admitted to labor ward who had registered for birth in AMU from 2010 to 2017. For the control group, low-risk women were selected; additionally, matching was performed for parity. Mode of birth was chosen as primary outcome parameter for the mother. For the neonate, a composite primary outcome (5-min Apgar < 7 or umbilical cord arterial pH < 7.10 or transfer to specialist neonatal care) was defined. Secondary outcomes included epidural anesthesia, duration of the second stage of labor, episiotomy, obstetric injury, and postpartum hemorrhage. Non-inferiority was assessed, and multiple logistic regression analysis was performed. RESULTS: Six hundred twelve women were admitted for labor in AMU, the control group consisted of 612 women giving birth in standard obstetric care. Women in the study group were on average older and had a higher body mass index (BMI); birthweight was on average 95 g higher. Non-inferiority could be established for the primary outcome parameters. Epidural anesthesia and episiotomy rates were lower, and the mean duration of the second stage of labor was shorter in the study group; second-degree perineal tears were less common, higher-order obstetric lacerations occurred more frequently. Overall, 50.3% of women were transferred to standard obstetric care. Regression analysis revealed effects of parity, age and birthweight on the chance of transfer. CONCLUSION: Compared to births in our consultant-led obstetric unit, the outcome of births planned in the AMU was not inferior, and intervention rates were lower. Our results support the integration of AMU as a complementary model of care for low-risk women.

The contribution of iron deficiency to the risk of peripartum transfusion: a retrospective case control study.

BACKGROUND: Iron deficiency in pregnancy is associated with inferior maternal and fetal outcomes. Postpartum depression, prematurity, intrauterine growth restriction, impaired childhood cognition and transfusion are all sequelae of maternal iron deficiency anemia. Transfusion to women of childbearing age has important consequences including increasing the risk of hemolytic disease of the fetus and newborn with future pregnancies. The relative contribution of iron deficiency to transfusion rates in the peripartum period is unknown. This study aimed to identify the prevalence of iron deficiency and anemia in pregnant women that received peripartum transfusions relative to age-matched non-transfused controls. METHODS: We performed a retrospective case-control study of all women that were transfused in the peripartum period from January, 2014 to July, 2018. Cases were compared to the next age matched control to deliver at our institution. The primary objective was to determine the proportion of patients with iron deficiency in pregnancy or anemia in pregnancy in cases and controls. Charts were reviewed for predisposing risk factors for iron deficiency, laboratory measures of iron deficiency and anemia, iron supplementation history and maternal and fetal outcomes. Factors associated with peripartum transfusion were analyzed using a multivariate logistic regression. RESULTS: 169 of 18, 294 (0.9%) women were transfused in the peripartum period and 64 (44%) of those transfused received 1 unit. Iron deficiency or anemia were present in 103 (71%) transfused women and 74 (51%) control women in pregnancy (OR 2.34, 95% CI: 3.7-18.0). Multivariate analysis identified social work involvement (adjusted OR 4.1, 95% CI: 1.8-10.1), intravenous iron supplementation in pregnancy (adjusted OR 3.8, 95% CI: 1.2-17.4) and delivery by unscheduled cesarean section (adjusted OR 2.8, 95% CI: 1.3-6.2) as significant predictors of peripartum transfusion. CONCLUSIONS: Pregnant women being followed by a social worker, receiving intravenous iron supplementation in pregnancy or who deliver by unscheduled cesarean section are more likely to receive a red blood cell transfusion. Women with iron deficiency or anemia in pregnancy are at increased risk of peripartum blood transfusions and warrant early and rigorous iron supplementation.