Predictors of perinatal mortality in Liberia's post-civil unrest: A comparative analysis of the 2013 and 2019-2020 Liberia Demographic and Health Surveys.

INTRODUCTION: Perinatal mortality remains a pressing concern, especially in lower and middle-income nations. Globally, 1 in 72 babies are stillborn. Despite advancements, the 2030 targets are challenging, notably in sub-Saharan Africa. Post-war Liberia saw a 14% spike in perinatal mortality between 2013 and 2020, indicating the urgency for in-depth study. OBJECTIVE: The study aims to investigate the predictors of perinatal mortality in Liberia using 2013 and 2019-2020 Liberia Demographic and Health Survey datasets. METHODS: In a two-stage cluster design from the Liberia Demographic and Health Survey, 6572 and 5285 respondents were analysed for 2013 and 2019-2020, respectively. Data included women aged 15-49 with pregnancy histories. Descriptive statistics was used to analyse the sociodemographic characteristics, the exposure to media and the maternal health services. Bivariate and multivariate logistic regressions were used to examine the predictors of perinatal mortality at a significance level of p value ≤0.05 and 95% CI. The data analysis was conducted in STATA V.14. RESULTS: Perinatal mortality rates increased from 30.23 per 1000 births in 2013 to 42.05 in 2019-2020. In 2013, increasing age of respondents showed a reduced risk of perinatal mortality rate. In both years, having one to three children significantly reduced mortality risk (2013: adjusted OR (aOR) 0.30, 95% CI 0.14 to 0.64; 2019: aOR 0.24, 95% CI 0.11 to 0.54), compared with not having a child. Weekly radio listenership increased mortality risk (2013: aOR 1.36, 95% CI 0.99 to 1.89; 2019: aOR 1.86, 95% CI 1.35 to 2.57) compared with not listening at all. Longer pregnancy intervals (p<0.0001) and receiving 2+ tetanus injections (p=0.019) were protective across both periods. However, iron supplementation showed varied effects, reducing risk in 2013 (aOR 0.90, 95% CI 0.48 to 1.68) but increasing it in 2019 (aOR 2.10, 95% CI 0.90 to 4.92). CONCLUSION: The study reports an alarming increase in Liberia's perinatal mortality from 2013 to 2019-2020. The findings show dynamic risk factors necessitating adaptable healthcare approaches, particularly during antenatal care. These adaptable approaches are crucial for refining health strategies in line with the Sustainable Development Goals, with emphasis on the integration of health, education, gender equality, sustainable livelihoods and global partnerships for effective health outcomes.

Atuação da psicologia em unidade neonatal no contexto da pandemia da covid-19 / The work of psychology in a neonatal unit in the covid-19 pandemic / Actuación de la psicología en una unidad neonatal en el contexto de la pandemia de la covid-19

A pandemia de covid-19 provocou intensas mudanças no contexto do cuidado neonatal, exigindo dos profissionais de saúde a reformulação de práticas e o desenvolvimento de novas estratégias para a manutenção da atenção integral e humanizada ao recém-nascido. O objetivo deste artigo é relatar a atuação da Psicologia nas Unidades Neonatais de um hospital público de Fortaleza (CE), Brasil, durante o período de distanciamento físico da pandemia de covid-19. Trata-se de estudo descritivo, do tipo relato de experiência, que ocorreu no período de março a agosto de 2020. No contexto pandêmico, o serviço de Psicologia desenvolveu novas condutas assistenciais para atender às demandas emergentes do momento, como: atendimento remoto; registro e envio on-line de imagens do recém-nascido a seus familiares; visitas virtuais; e reprodução de mensagens de áudio da família para o neonato. Apesar dos desafios encontrados, as ações contribuíram para a manutenção do cuidado centrado no recém-nascido e sua família, o que demonstra a potencialidade do fazer psicológico.(AU)

The COVID-19 pandemic brought intense changes to neonatal care and required health professionals to reformulate practices and develop new strategies to ensure comprehensive and humanized care for newborn. This study aims to report the experience of the Psychology Service in the Neonatal Units of a public hospital in Fortaleza, in the state of Ceará, Brazil, during the social distancing period of the COVID-19 pandemic. This descriptive experience report study was conducted from March to August 2020. During the pandemic, the Psychology Service developed new care practices to meet the emerging demands of that moment, such as remote care, recordings and online submission of newborns' pictures and video images for their family, virtual tours, and reproduction of family audio messages for the newborns. Despite the challenges, the actions contributed to the maintenance of a care that is centered on the newborns and their families, which shows the potential of psychological practices.(AU)

La pandemia de la COVID-19 ha traído cambios intensos en el contexto de la atención neonatal, que requieren de los profesionales de la salud una reformulación de sus prácticas y el desarrollo de nuevas estrategias para asegurar una atención integral y humanizada al recién nacido. El objetivo de este artículo es reportar la experiencia del Servicio de Psicología en las Unidades Neonatales de un hospital público de Fortaleza, en Ceará, Brasil, durante el periodo de distanciamiento físico en la pandemia de la COVID-19. Se trata de un estudio descriptivo, un reporte de experiencia, que se llevó a cabo de marzo a agosto de 2020. En el contexto pandémico, el servicio de Psicología desarrolló nuevas conductas asistenciales para atender a las demandas emergentes del momento, tales como: atención remota; grabación y envío em línea de imágenes del recién nacido; visitas virtuales; y reproducción de mensajes de audio de la familia para el recién nacido. A pesar de los desafíos encontrados, las acciones contribuyeron al mantenimiento de la atención centrada en el recién nacido y su familia, lo que demuestra el potencial de la práctica psicológica.(AU)

Protocol for a cluster randomised controlled trial of LPG cookstoves compared to usual cooking practices to reduce perinatal mortality and morbidity in rural Bangladesh called Poriborton: the CHANge trial.

BACKGROUND: Household air pollution is a leading health risk for global morbidity and mortality and a major health risk in South Asia. However, there are no prospective investigations of the impact of household air pollution on perinatal morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on perinatal morbidity and mortality compared to usual cooking practices in Bangladesh. HYPOTHESIS: In a community-based cluster randomised controlled trial of pregnant women cooking with LPG throughout pregnancy, perinatal mortality will be reduced by 35% compared with usual cooking practices in a rural community in Bangladesh. METHODS: A two-arm community-based cluster randomised controlled trial will be conducted in the Sherpur district, Bangladesh. In the intervention arm, pregnant women receive an LPG cookstove and LPG in cylinders supplied throughout pregnancy until birth. In the control or usual practice arm, pregnant women continue their usual cooking practices, predominately traditional stoves with biomass fuel. Eligible women are pregnant women with a gestational age of 40-120 days, aged between 15 and 49 years, and permanent residents of the study area. The primary outcome is the difference in perinatal mortality between the LPG arm and the usual cooking arm. Secondary outcomes include (i) preterm birth and low birth weight, (ii) personal level exposure to household air pollution, (iii) satisfaction and acceptability of the LPG stove and stove use, and (iv) cost-effectiveness and cost-utility in reducing perinatal morbidity and mortality. We follow up all women and infants to 45 days after the birth. Personal exposure to household air pollution is assessed at three-time points in a sub-sample of the study population using the MicroPEM™. The total required sample size is 4944 pregnant women. DISCUSSION: This trial will produce evidence of the effectiveness of reduced exposure to household air pollution through LPG cooking to reduce perinatal morbidity and mortality compared to usual cooking practices. This evidence will inform policies for the adoption of clean fuel in Bangladesh and other similar settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001214224 . Prospectively registered on 19 July 2019.

Maternal micronutrient status as a risk factor for perinatal mortality in a Tanzanian randomized controlled trial.

The objective of this study was to determine if maternal micronutrient status (specifically iron) during pregnancy is a risk factor for perinatal mortality among women in Tanzania. Secondary analysis of data from a randomized, double-blind, placebo-controlled vitamin A supplementation trial conducted between August 2010-March 2013 was used to assess iron intake among women who experienced a stillbirth or early neonatal death. The mean dietary iron intake (measured using a quantitative Food Frequency Questionnaire) for this population was 12.64 mg/day (SD = 6.32). There were 206 cases of perinatal mortality. Three classifications of dietary iron intake were devised and risk ratios were calculated using the Log Binomial Regression Model: <18 mg/day (RR: 2.13), 18-27 mg/day (RR: 2.63), & <27 mg/day (the reference group to which the first two classification groups were compared). There was neither a significant relationship found among women who consumed iron levels <18 mg/day or between 18-27 mg/day of iron compared to women who consumed more than 27 mg/day of iron, but on average there was twice the risk for perinatal mortality. The current study is consistent with previous literature findings and supports the need for more efficacious nutrition strategies.

Maternal micronutrient status as a risk factor for perinatal mortality in a Tanzanian randomized controlled trial

The objective of this study was to determine if maternal micronutrient status (specifically iron) during pregnancy is a risk factor for perinatal mortality among women in Tanzania. Secondary analysis of data from a randomized, double-blind, placebo-controlled vitamin A supplementation trial conducted between August 2010-March 2013 was used to assess iron intake among women who experienced a stillbirth or early neonatal death. The mean dietary iron intake (measured using a quantitative Food Frequency Questionnaire) for this population was 12.64 mg/day (SD = 6.32). There were 206 cases of perinatal mortality. Three classifications of dietary iron intake were devised and risk ratios were calculated using the Log Binomial Regression Model: <18 mg/day (RR: 2.13), 18-27 mg/day (RR: 2.63), & >27 mg/day (the reference group to which the first two classification groups were compared).There was neither a significant relationship found among women who consumed iron levels <18 mg/day or between 18-27 mg/day of iron compared to women who consumed more than 27 mg/day of iron, but on average there was twice the risk for perinatalmortality. The current study is consistent with previous literature findings and supports the need for more efficacious nutrition strategies. (Afr J Reprod Health 2022; 26[7]: 38-48).

Birth Outcomes for Planned Home and Licensed Freestanding Birth Center Births in Washington State.

OBJECTIVE: To describe rates of maternal and perinatal birth outcomes for community births and to compare outcomes by planned place of birth (home vs state-licensed, freestanding birth center) in a Washington State birth cohort, where midwifery practice and integration mirrors international settings. METHODS: We conducted a retrospective cohort study including all births attended by members of a statewide midwifery professional association that were within professional association guidelines and met eligibility criteria for planned birth center birth (term gestation, singleton, vertex fetus with no known fluid abnormalities at term, no prior cesarean birth, no hypertensive disorders, no prepregnancy diabetes), from January 1, 2015 through June 30, 2020. Outcome rates were calculated for all planned community births in the cohort. Estimated relative risks were calculated comparing delivery and perinatal outcomes for planned births at home to state-licensed birth centers, adjusted for parity and other confounders. RESULTS: The study population included 10,609 births: 40.9% planned home and 59.1% planned birth center births. Intrapartum transfers to hospital were more frequent among nulliparous individuals (30.5%; 95% CI 29.2-31.9) than multiparous individuals (4.2%; 95% CI 3.6-4.6). The cesarean delivery rate was 11.4% (95% CI 10.2-12.3) in nulliparous individuals and 0.87% (95% CI 0.7-1.1) in multiparous individuals. The perinatal mortality rate after the onset of labor (intrapartum and neonatal deaths through 7 days) was 0.57 (95% CI 0.19-1.04) per 1,000 births. Rates for other adverse outcomes were also low. Compared with planned birth center births, planned home births had similar risks in crude and adjusted analyses. CONCLUSION: Rates of adverse outcomes for this cohort in a U.S. state with well-established and integrated community midwifery were low overall. Birth outcomes were similar for births planned at home or at a state-licensed, freestanding birth center.

Tocolysis in the management of preterm prelabor rupture of membranes at 22-33 weeks of gestation: study protocol for a multicenter, double-blind, randomized controlled trial comparing nifedipine with placebo (TOCOPROM).

BACKGROUND: Preterm prelabor rupture of membranes (PPROM) before 34 weeks of gestation complicates 1% of pregnancies and accounts for one-third of preterm births. International guidelines recommend expectant management, along with antenatal steroids before 34 weeks and antibiotics. Up-to-date evidence about the risks and benefits of administering tocolysis after PPROM, however, is lacking. In theory, reducing uterine contractility could delay delivery and reduce the risks of prematurity and its adverse short- and long-term consequences, but it might also prolong fetal exposure to inflammation, infection, and acute obstetric complications, potentially associated with neonatal death or long-term sequelae. The primary objective of this study is to assess whether short-term (48 h) tocolysis reduces perinatal mortality/morbidity in PPROM at 22 to 33 completed weeks of gestation. METHODS: A randomized, double-blind, placebo-controlled, superiority trial will be performed in 29 French maternity units. Women with PPROM between 220/7 and 336/7 weeks of gestation, a singleton pregnancy, and no condition contraindicating expectant management will be randomized to receive a 48-hour oral treatment by either nifedipine or placebo (1:1 ratio). The primary outcome will be the occurrence of perinatal mortality/morbidity, a composite outcome including fetal death, neonatal death, or severe neonatal morbidity before discharge. If we assume an alpha-risk of 0.05 and beta-risk of 0.20 (i.e., a statistical power of 80%), 702 women (351 per arm) are required to show a reduction of the primary endpoint from 35% (placebo group) to 25% (nifedipine group). We plan to increase the required number of subjects by 20%, to replace any patients who leave the study early. The total number of subjects required is thus 850. Data will be analyzed by the intention-to-treat principle. DISCUSSION: This trial will inform practices and policies worldwide. Optimized prenatal management to improve the prognosis of infants born preterm could benefit about 50,000 women in the European Union and 40,000 in the United States each year. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03976063 (registration date June 5, 2019).

Composite adverse outcomes in obstetric studies: a systematic review.

BACKGROUND: Composite outcomes are increasingly being used in obstetric trials. The aim of this systematic review is to critically appraise the use of composite outcomes in obstetric RCTs with an intention of identifying limitations and providing potential solutions for future research. METHODS: The study protocol was prospectively registered. Medline, Embase, Cochrane Databases and www.clinicaltrials.gov were searched for randomized controlled trials (RCTs) published in English between 1999 and 2019, using search terms related to pregnancy and composite outcomes. STUDY ELIGIBILITY CRITERIA: RCTs involving an obstetric condition that reported on a composite outcome. STUDY APPRAISAL AND SYNTHESIS METHODS: Screening and data extraction were performed in duplicate, and a descriptive synthesis and critical appraisal of composite obstetric outcomes, is presented. RESULTS: Of the 4170 results screened, we identified 156 RCTs, reporting on 181 composite outcomes. Of these, 158 composite outcomes related to general morbidity and mortality, either exclusively maternal (n=20), fetal-neonatal [perinatal] (n=116) or maternal and perinatal (n=22) were included in the final analysis. Obstetric composite outcomes included between two and 16 components. Components that comprised these composite outcomes were often dissimilar in terms of severity and frequency of occurrence, unlikely to have similar relative risk reductions and sometimes unrelated to the study's primary objective - important pre-requisites to consider while constructing composite outcomes. In addition, composite adverse obstetric outcomes often do not incorporate the perspectives of pregnant persons, embrace a holistic view of health or consider outcomes related to both members of the mother-fetus dyad. CONCLUSIONS: Composite outcomes are being increasingly used as primary outcomes in obstetric RCTs, based on which study conclusions are drawn and clinical recommendations made. However, there is a lack of consistency with regard to what components should be included within a composite adverse obstetric outcome and how these components should be measured. The use of novel research methods such as concept mapping may be able to address some of the limitations with the development of composite adverse obstetric outcomes, to inform future research.

Old Question Revisited: Are High-Protein Diets Safe in Pregnancy?

BACKGROUND: A previous randomized dietary intervention in pregnant women from the 1970s, the Harlem Trial, reported retarded fetal growth and excesses of very early preterm births and neonatal deaths among those receiving high-protein supplementation. Due to ethical challenges, these findings have not been addressed in intervention settings. Exploring these findings in an observational setting requires large statistical power due to the low prevalence of these outcomes. The aim of this study was to investigate if the findings on high protein intake could be replicated in an observational setting by combining data from two large birth cohorts. METHODS: Individual participant data on singleton pregnancies from the Danish National Birth Cohort (DNBC) (n = 60,141) and the Norwegian Mother, Father and Child Cohort Study (MoBa) (n = 66,302) were merged after a thorough harmonization process. Diet was recorded in mid-pregnancy and information on birth outcomes was extracted from national birth registries. RESULTS: The prevalence of preterm delivery, low birth weight and fetal and neonatal deaths was 4.77%, 2.93%, 0.28% and 0.17%, respectively. Mean protein intake (standard deviation) was 89 g/day (23). Overall high protein intake (>100 g/day) was neither associated with low birth weight nor fetal or neonatal death. Mean birth weight was essentially unchanged at high protein intakes. A modest increased risk of preterm delivery [odds ratio (OR): 1.10 (95% confidence interval (CI): 1.01, 1.19)] was observed for high (>100 g/day) compared to moderate protein intake (80-90 g/day). This estimate was driven by late preterm deliveries (weeks 34 to <37) and greater risk was not observed at more extreme intakes. Very low (<60 g/day) compared to moderate protein intake was associated with higher risk of having low-birth weight infants [OR: 1.59 (95%CI: 1.25, 2.03)]. CONCLUSIONS: High protein intake was weakly associated with preterm delivery. Contrary to the results from the Harlem Trial, no indications of deleterious effects on fetal growth or perinatal mortality were observed.

Mortalidad evitable en la vigilancia de la mortalidad perinatal y neonatal, Colombia, 2017 y 2018 / Avoidable mortality in perinatal and neonatal mortality care, Colombia, 2017 and 2018

INTRODUCCIÓN: La mortalidad perinatal y neonatal representa la calidad de la atención en el periodo anteparto, parto y en la etapa neonatal; también refleja las condiciones sociales, económicas, biológicas, conductuales políticas, ambientales y el acceso a los servicios de salud, siendo características relacionadas con la mortalidad evitable. El objetivo de este trabajo es describir el comportamiento de la mortalidad evitable en el periodo perinatal y neonatal para Colombia en el año 2017 y 2018 de acuerdo con las metodologías disponibles en la literatura. MATERIAL Y MÉTODOS: Se realizó un estudio descriptivo de corte transversal de las muertes perinatales y neonatales tardías registradas en Colombia para 2017 y 2018. La fuente de información se obtiene a través de la notificación individual semanal de casos al Sistema de Vigilancia en Salud Pública (Sivigila). RESULTADOS: La proporción más alta de mortalidad evitable a través de la aplicación del proyecto europeo AMIEHS (Amenable Mortality in the European Union: towards better Indicators for the Effectiveness of Health Systems) fue del 84,3% para el 2017 y el 83,9% para el 2018. DISCUSIÓN: En Colombia, la aplicación de la metodología del proyecto AMEHIS evidenció que el 84% de las mortalidades perinatales y neonatales notificadas pudieron ser evitadas, con una tasa 13,6 muertes por 1.000 nacidos vivos. Esto ratifica la necesidad de fortalecer las estrategias orientadas a impactar de manera positiva los determinantes sociales, por medio de acciones de promoción y prevención, detección temprana y atención integral. (AU)

INTRODUCTION: perinatal and neonatal mortality reflects the quality in the antepartum, delivery, and neonatal care period; it also reflects social, economic, biological, political, behavioral, and environmental conditions as well as access to health service characteristics related to avoidable mortality. The objective of this study is to describe the avoidable mortality behavior in the perinatal and neonatal period in Colombia in 2017 and 2018 based on methodologies discussed in the literature. MATERIALS AND METHODS: a descriptive cross-sectional study of perinatal and late neonatal deaths registered in Colombia in 2017 and 2018 was made. Information was obtained through the weekly individual notification of cases to the Public Health Surveillance System (Sivigila). RESULTS: the highest proportion of avoidable mortality by implementing the European project AMIEHS (Amenable Mortality in the European Union: Towards better Indicators for the Effec-tiveness of Health Systems) was 84.3% for 2017 and 83.9 % for 2018. DISCUSSION: in Colombia, the application of AMEHIS project methodology showed that 84% of the perinatal and neonatal reported mortalities could be avoided, with a rate of 13.6 deaths per 1,000 live births. This confirms the need to strengthen strategies to positively influence social determinants through promotion, prevention, early detection, and comprehensive care. (AU)

The effect of the community midwifery model on maternal and newborn health service utilization and outcomes in Busia County of Kenya: a quasi-experimental study.

BACKGROUND: Poor women in hard-to-reach areas are least likely to receive healthcare and thus carry the burden of maternal and perinatal mortality from complications of childbirth. This study evaluated the effect of an enhanced community midwifery model on skilled attendance during pregnancy/childbirth as well as on maternal and perinatal outcomes against the backdrop of protracted healthcare workers' strikes in rural Kenya. METHODS: The study used a quasi-experimental (one-group pretest-posttest) design. The study spanned three time periods: December 2016-February 2017 when doctors were on strike (P1), March-May 2017 when no healthcare providers were on strike (P2), and June-October 2017 when nurses/midwives were on strike (P3), which was also the period when the project enhanced the capacity of community midwives (CMs) to provide services at the community level. Analysis entailed comparison of frequencies/means of maternal and newborn health service utilization data across the three periods. RESULTS: The monthly average number of clients obtaining services from CMs across the three time periods was: first antenatal care (ANC) (P1-1.8, P2-2.3, P3-9.9), fourth ANC (P1-1.4, P2-1.0, P3-7.1), skilled birth (P1-1.5, P2-1.7, P3-13.1) and the differences in means were statistically significant (p < 0.05). Over the period, the monthly average number of clients obtaining services from health facilities was: first ANC (P1-55.7, P2-70.8, P3-4.0), fourth ANC (P1-29.6, P2-38.1, P3-1.2) and skilled birth (P1-63.1, P2-87.4, P3-5.6), p < 0.05. There were no statistically significant differences in the average number of clients obtaining services from CMs or health facilities between P1 and P2 (p > 0.05). There was, however, a statistically significant increase in the average number of clients obtaining services from CMs in P3 accompanied by a statistically significant decline in the average number of clients obtaining services from health facilities (p < 0.05). First ANC increased by 68%, fourth ANC by 75%, skilled births by 68%, and postnatal care by 33% in P3 (p < 0.0001). There was a non-significant decline in macerated stillbirths and neonatal deaths in P3. CONCLUSIONS: The findings underscore the importance of integrating community-level health service providers (CMs and health volunteers) into the primary health care system to complement service delivery according to their level of expertise, especially in low-resource settings.

Impact of regionalisation and case-volume on neonatal and perinatal mortality: an umbrella review.

OBJECTIVE: This umbrella review summarises and critically appraises the evidence on the effects of regulated or high-volume perinatal care on outcome among very low birth weight/very preterm infants born in countries with neonatal mortality <5/1000 births. INTERVENTION/EXPOSITION: Perinatal regionalisation, centralisation, case-volume. PRIMARY OUTCOMES: Death. SECONDARY OUTCOMES: Disability, discomfort, disease, dissatisfaction. METHODS: On 29 November 2019 a systematic search in MEDLINE and Embase was performed and supplemented by hand search. Relevant systematic reviews (SRs) were critically appraised with A MeaSurement Tool to Assess systematic Reviews 2. RESULTS: The literature search revealed 508 hits and three SRs were included. Effects of perinatal regionalisation were assessed in three (34 studies) and case-volume in one SR (6 studies). Centralisation has not been evaluated. The included SRs reported effects on 'death' (eg, neonatal), 'disability' (eg, mental status), 'discomfort' (eg, maternal sensitivity) and 'disease' (eg, intraventricular haemorrhages). 'Dissatisfactions' were not reported. The critical appraisal showed a heterogeneous quality ranging from moderate to critically low. A pooled effect estimate was reported once and showed a significant favour of perinatal regionalisation in terms of neonatal mortality (OR 1.60, 95% CI 1.33-1.92). The qualitative evidence synthesis of the two SRs without pooled estimate suggests superiority of perinatal regionalisation in terms of different mortality and non-mortality outcomes. In one SR, contradictory results of lower neonatal mortality rates were reported in hospitals with higher birth volumes. CONCLUSIONS: Regionalised perinatal care seems to be a crucial care strategy to improve the survival of very low birth weight and preterm births. To overcome the low and critically low methodological quality and to consider additional clinical and patient-reported results that were not addressed by the SRs included, we recommend an updated SR. In the long term, an international, uniformly conceived and defined perinatal database could help to provide evidence-based recommendations on optimal strategies to regionalise perinatal care. PROSPERO REGISTRATION NUMBER: CRD42018094835.

Coaching Intensity, Adherence to Essential Birth Practices, and Health Outcomes in the BetterBirth Trial in Uttar Pradesh, India.

BACKGROUND: Coaching can improve the quality of care in primary-level birth facilities and promote birth attendant adherence to essential birth practices (EBPs) that reduce maternal and perinatal mortality. The intensity of coaching needed to promote and sustain behavior change is unknown. We investigated the relationship between coaching intensity, EBP adherence, and maternal and perinatal health outcomes using data from the BetterBirth Trial, which assessed the impact of a complex, coaching-based implementation of the World Health Organization's Safe Childbirth Checklist in Uttar Pradesh, India. METHODS: For each birth, we defined multiple coaching intensity metrics, including coaching frequency (coaching visits per month), cumulative coaching (total coaching visits accrued during the intervention), and scheduling adherence (coaching delivered as scheduled). We considered coaching delivered at both facility and birth attendant levels. We assessed the association between coaching intensity and birth attendant adherence to 18 EBPs and with maternal and perinatal health outcomes using regression models. RESULTS: Coaching frequency was associated with modestly increased EBP adherence. Delivering 6 coaching visits per month to facilities was associated with adherence to 1.3 additional EBPs (95% confidence interval [CI]=0.6, 1.9). High-frequency coaching delivered with high coverage among birth attendants was associated with greater improvements: providing 70% of birth attendants at a facility with at least 1 visit per month was associated with adherence to 2.0 additional EBPs (95% CI=1.0, 2.9). Neither cumulative coaching nor scheduling adherence was associated with EBP adherence. Coaching was generally not associated with health outcomes, possibly due to the small magnitude of association between coaching and EBP adherence. CONCLUSIONS: Frequent coaching may promote behavior change, especially if delivered with high coverage among birth attendants. However, the effects of coaching were modest and did not persist over time, suggesting that future coaching-based interventions should explore providing frequent coaching for longer periods.

Provision of Care to Preterm Infants at Resource Limited Health Facilities of Mopani District, South Africa.

Background: Inadequate neonatal facilities in rural areas is one of the challenges affecting the management of preterm infants. In low income countries with limited resources, over 90% of preterm babies die within few days of life. Purpose: The purpose of this study was to describe the challenges encountered by midwives when providing care to preterm infants at resource limited health facilities in Limpopo Province, South Africa. Methods: Qualitative research approach, using exploratory and descriptive design was used. Non-probability purposive sampling was used to select twenty three midwives who had an experience of two or more years in maternity. Data was collected using unstructured individual interviews, which were voice recorded and transcribed and data analysed qualitatively through the open-coding method. Findings: Revealed one theme, preterm condition and expected care; with sub-themes namely; perceived causes of preterm complications and deaths, preterm babies experience several difficulties which need specialised care, the need for constant individualised care and monitoring of preterm infants by midwives, functional relevant equipment needed for care of preterm infants, a need for constant training for midwives regarding care of preterm infants, and importance for a proper structure to house preterm infants which will lead to quality care provision. Conclusion: Preterm babies need simple essential care such as warmth, feeding support, safe oxygen use and prevention of infection. Lack of adequate resources and limited skills from midwives could contribute to morbidity and mortality. Health facility managers need to create opportunities for basic and advanced preterm care to equip the skills of midwives by sending them to special trainings such as Limpopo Initiative Neonatal Care (LINC), Helping Baby Breath (HHB) and Neonatal Intensive Care Unit (NICU). Operational managers should be involved in the identification, procurement and supply of required equipment. Continuous health education should be provided on the mothers about kangaroo mother care (KMC) and measures to prevent infections in the neonatal unit.

Nurses' and auxiliary nurse midwives' adherence to essential birth practices with peer coaching in Uttar Pradesh, India: a secondary analysis of the BetterBirth trial.

BACKGROUND: The BetterBirth trial tested the effect of a peer coaching program around the WHO Safe Childbirth Checklist for birth attendants in primary-level facilities in Uttar Pradesh, India on a composite measure of perinatal and maternal mortality and maternal morbidity. This study aimed to examine the adherence to essential birth practices between two different cadres of birth attendants-nurses and auxiliary nurse midwives (ANMs)-during and after a peer coaching intervention for the WHO Safe Childbirth Checklist. METHODS: This is a secondary analysis of birth attendant characteristics, coaching visits, and behavior uptake during the BetterBirth trial through birth attendant surveys, coach observations, and independent observations. Descriptive statistics were calculated overall, and by staffing cadre (staff nurses and ANMs) for demographic characteristics. Logistic regression using the Pearson overdispersion correction (to account for clustering by site) was used to assess differences between staff nurses and ANMs in the intervention group during regular coaching (2-month time point) and 4 months after the coaching program ended (12-month time point). RESULTS: Of the 570 birth attendants who responded to the survey in intervention and control arms, 474 were staff nurses (83.2%) and 96 were ANMs (16.8%). In the intervention arm, more staff nurses (240/260, 92.3%) received coaching at all pause points compared to ANMs (40/53, 75.5%). At baseline, adherence to practices was similar between ANMs and staff nurses (~ 30%). Overall percent adherence to essential birth practices among ANMs and nurses was highest at 2 months after intervention initiation, when frequent coaching visits occurred (68.1% and 64.1%, respectively, p = 0.76). Practice adherence tapered to 49.2% among ANMs and 56.1% among staff nurses at 12 months, which was 4 months after coaching had ended (p = 0.68). CONCLUSIONS: Overall, ANMs and nurses responded similarly to the coaching intervention with the greatest increase in percent adherence to essential birth practices after 2 months of coaching and subsequent decrease in adherence 4 months after coaching ended. While coaching is an effective strategy to support some aspects of birth attendant competency, the structure, content, and frequency of coaching may need to be customized according to the birth attendant training and competency. TRIAL REGISTRATION: ClinicalTrials.gov: NCT2148952; Universal Trial Number: U1111-1131-5647.

Reduction in Perinatal Mortality after Implementation of HBB Training at a District Hospital in Mali.

BACKGROUND: Mali has a high neonatal mortality rate of 38/1000 live births; in addition the fresh stillbirth rate (FSR) is 23/1000 births and of these one-third are caused by intrapartum events. OBJECTIVES: The aims are to evaluate the effect of helping babies breathe (HBB) on mortality rate at a district hospital in Kati district, Mali. METHODS: HBB first edition was implemented in April 2016. One year later the birth attendants were trained in HBB second edition and started frequent repetition training. This is a before and after study comparing the perinatal mortality during the period before HBB training with the period after HBB training, the period after HBB first edition and the period after HBB second edition. Perinatal mortality is defined as FSR plus neonatal deaths in the first 24 h of life. RESULTS: There was a significant reduction in perinatal mortality rate (PMR) between the period before and after HBB training, from 21.7/1000 births to 6.0/1000 live births; RR 0.27, (95% CI 0.19-0.41; p < 0.0001). Very early neonatal mortality rate (24 h) decreased significantly from 6.3/1000 to 0.8/1000 live births; RR 0.12 (95% CI 0.05-0.33; p = 0.0006). FSR decreased from 15.7/1000 to 5.3/1000, RR 0.33 (95% CI 0.22-0.52; p < 0.0001). No further reduction occurred after introducing the HBB second edition. CONCLUSION: HBB may be effective in a local first-level referral hospital in Mali.

Intrapartum and neonatal mortality in low-risk term women in midwife-led care and obstetrician-led care at the onset of labor: A national matched cohort study.

INTRODUCTION: Midwife-led models of care have been the subject of debate for many years. We conducted a study to compare intrapartum and neonatal mortality rates in midwife-led (primary) vs obstetrician-led (secondary) care at the onset of labor in low-risk term women. MATERIAL AND METHODS: We performed an unmatched and a propensity score matched cohort study using data from the national perinatal audit registry (PAN) and from the national perinatal registry (PERINED) of the Netherlands. We included women with singleton pregnancies (without congenital anomalies or antepartum fetal death) who gave birth at term between 2010 and 2012. We excluded the following major risk factors: non-vertex position of the fetus, previous cesarean birth, hypertension, diabetes mellitus, prolonged rupture of membranes (≥24 hours), vaginal bleeding in the second half of pregnancy, nonspontaneous start of labor and post-term pregnancy (≥42 weeks). The primary outcome was intrapartum or neonatal mortality up to 28 days after birth. Secondary outcome measures were mode of delivery and a 5-minute Apgar score <7. RESULTS: We included 259 211 women. There were 100/206 642 (0.48‰) intrapartum and neonatal deaths in the midwife group and 23/52 569 (0.44‰) in the obstetrician group (odds ratio [OR] 1.11, 95% CI 0.70-1.74). Propensity score matched analysis showed mortality rates of 0.49‰ (26/52 569) among women in midwife-led care and 0.44‰ (23/52 569) for women in obstetrician-led care (OR 1.13, 95% CI 0.65-1.98). In the midwife group there were significantly lower rates of vaginal instrumental deliveries (8.4% vs 13.0%; matched OR 0.65, 95% CI 0.62-0.67) and intrapartum cesarean sections (2.6% vs 8.2%; matched OR 0.32, 95% CI 0.30-0.34), and fewer neonates with low Apgar scores (<7 after 5 minutes) (0.69% vs 1.11%; matched OR 0.61, 95% CI 0.53-0.69). CONCLUSIONS: Among low-risk term women, there were comparable intrapartum and neonatal mortality rates for women starting labor in midwife-led vs obstetrician-led care, with lower intervention rates and fewer low Apgar scores in the midwife group.

Effectiveness of routine third trimester ultrasonography to reduce adverse perinatal outcomes in low risk pregnancy (the IRIS study): nationwide, pragmatic, multicentre, stepped wedge cluster randomised trial.

OBJECTIVES: To investigate the effectiveness of routine ultrasonography in the third trimester in reducing adverse perinatal outcomes in low risk pregnancies compared with usual care and the effect of this policy on maternal outcomes and obstetric interventions. DESIGN: Pragmatic, multicentre, stepped wedge cluster randomised trial. SETTING: 60 midwifery practices in the Netherlands. PARTICIPANTS: 13 046 women aged 16 years or older with a low risk singleton pregnancy. INTERVENTIONS: 60 midwifery practices offered usual care (serial fundal height measurements with clinically indicated ultrasonography). After 3, 7, and 10 months, a third of the practices were randomised to the intervention strategy. As well as receiving usual care, women in the intervention strategy were offered two routine biometry scans at 28-30 and 34-36 weeks' gestation. The same multidisciplinary protocol for detecting and managing fetal growth restriction was used in both strategies. MAIN OUTCOME MEASURES: The primary outcome measure was a composite of severe adverse perinatal outcomes: perinatal death, Apgar score <4, impaired consciousness, asphyxia, seizures, assisted ventilation, septicaemia, meningitis, bronchopulmonary dysplasia, intraventricular haemorrhage, periventricular leucomalacia, or necrotising enterocolitis. Secondary outcomes were two composite measures of severe maternal morbidity, and spontaneous labour and birth. RESULTS: Between 1 February 2015 and 29 February 2016, 60 midwifery practices enrolled 13 520 women in mid-pregnancy (mean 22.8 (SD 2.4) weeks' gestation). 13 046 women (intervention n=7067, usual care n=5979) with data based on the national Dutch perinatal registry or hospital records were included in the analyses. Small for gestational age at birth was significantly more often detected in the intervention group than in the usual care group (179 of 556 (32%) v 78 of 407 (19%), P<0.001). The incidence of severe adverse perinatal outcomes was 1.7% (n=118) for the intervention strategy and 1.8% (n=106) for usual care. After adjustment for confounders, the difference between the groups was not significant (odds ratio 0.88, 95% confidence interval 0.70 to 1.20). The intervention strategy showed a higher incidence of induction of labour (1.16, 1.04 to 1.30) and a lower incidence of augmentation of labour (0.78, 0.71 to 0.85). Maternal outcomes and other obstetric interventions did not differ between the strategies. CONCLUSION: In low risk pregnancies, routine ultrasonography in the third trimester along with clinically indicated ultrasonography was associated with higher antenatal detection of small for gestational age fetuses but not with a reduced incidence of severe adverse perinatal outcomes compared with usual care alone. The findings do not support routine ultrasonography in the third trimester for low risk pregnancies. TRIAL REGISTRATION: Netherlands Trial Register NTR4367.

Comparison of perinatal outcomes in facilities before and after Global Network's Helping Babies Breathe Implementation Study in Nagpur, India.

BACKGROUND: The Helping Babies Breathe (HBB) educational program focuses on training of first-level birth attendants in neonatal resuscitation skills for the first minute of life (The Golden Minute). Pre-post studies of HBB implementation in sub-Saharan Africa and Asia have shown reductions in facility-based very early neonatal mortality and stillbirth rates. However, the Global Network pre-post HBB Implementation Study (GN-HBB-IS) found no difference in day 7 perinatal mortality rates (PMR-D7) among births to women participating in the Global Network's Maternal and Newborn Health Registry. To address potential differences in perinatal outcomes in births occurring in facilities that implemented HBB vs. all births occurring in the communities served by facilities that implemented HBB, we compared day-1 perinatal mortality rates (PMR-D1) among births occurring pre and post HBB implementation in facilities in Nagpur, India, one of the 3 sites participating in the GN-HBB-IS. METHODS: We hypothesized that there would be a 20% decrease in the Nagpur facility based PMR-D1 in the 12 months post GN HBB implementation from the pre-period. We explored pre-post differences in stillbirth rates (SBR) and day-1 neonatal mortality rates (NMR-D1). RESULTS: Of the 15 facilities trained for the GN-HBB-IS, 13 participated in the Nagpur HBB Facility Study (Nagpur-HBB-FS). There were 38,078 facility births in the 12 months before the GN-HBB-IS and 40,870 facility births in the 12 months after the GN-HBB-IS. There was 11% overlap between the registry births analyzed in the GN-HBB-IS and the facility births analyzed in the Nagpur-HBB-FS. In the Nagpur-HBB-FS, there was a pre-post reduction of 16% in PMR-D1 (p = 0.0001), a 14% reduction in SBR (p = 0.002) and a 20% reduction NMR-D1 (p = 0.006). CONCLUSIONS: In the Nagpur-HBB-FS, PMR-D1, stillbirths and NMR-D1 were significantly lower after HBB implementation. These benefits did not translate to improvements in PMR-D7 in communities served by these facilities, possibly because facilities in which HBB was implemented covered an insufficient proportion of community births or because additional interventions are needed after day 1 of life. Further studies are needed to determine how to translate facility-based improvements in PMR-D1 to improved neonatal survival in the community. TRIAL REGISTRATION: The Global Network HBB Implementation Study (GN-HBB-IS) was registered at ClinicalTrials.gov: NCT01681017 .

The Use of Indomethacin with Complete Amniotic Fluid Replacement and Classic Hysterotomy for the Reduction of Perinatal Complications of Intrauterine Myelomeningocele Repair.

OBJECTIVE: This study presented outcomes of classical hysterotomy with modified antiprostaglandin therapy for intrauterine repair of foetal myelomeningocele (fMMC) performed in a single perinatal centre. STUDY DESIGN: Forty-nine pregnant women diagnosed with fMMC underwent classic hysterotomy with anti-prostaglandin management, complete amniotic fluid replacement and high dose indomethacin application. RESULTS: The average gestational age (GA) at delivery was 34.4 ± 3.4 weeks, with no births before 30 weeks GA. There were 2 foetal deaths. Complete reversal of hindbrain herniation (HH), assessed in magnetic resonance imaging at 30-31 weeks GA was found in 72% of foetuses (mostly with HH grade I prior to fMMC repair). Our protocol resulted in rare use of magnesium sulphate (6%), low incidence of chorioamniotic membrane separation - chorioamniotic membrane separation (6%), preterm premature rupture of membranes - preterm premature rupture of membranes (pPROM; 15%) and preterm labour - preterm labour (PTL; 17%). The postoperative wound continuity of the uterus was usually stable (in 72% of patients), with low frequency of scar thinning (23%). CONCLUSION: Our protocol results in rare use of tocolytics, and the low occurrences of CMS, pPROM and PTL in relation to other study cohorts: Management of Myelomeningocele Study, Children's Hospital of Philadelphia, and Vanderbilt University Medical Centre.