Global health systems strengthening: FIGO's strategic view on reducing maternal and newborn mortality worldwide.

OBJECTIVE: To demonstrate that successful health systems strengthening (HSS) projects have addressed disparities and inequities in maternal and perinatal care in low-income countries. METHODS: A comprehensive literature review covered the period between 1980 and 2022, focusing on successful HSS interventions within health systems' seven core components that improved maternal and perinatal care. RESULTS: The findings highlight the importance of integrating quality interventions into robust health systems, as this has been shown to reduce maternal and newborn mortality. However, several challenges, including service delivery gaps, poor data use, and funding deficits, continue to hinder the delivery of quality care. To improve maternal and newborn health outcomes, a comprehensive HSS strategy is essential, which should include infrastructure enhancement, workforce skill development, access to essential medicines, and active community engagement. CONCLUSION: Effective health systems, leadership, and community engagement are crucial for a comprehensive HSS approach to catalyze progress toward universal health coverage and global improvements in maternal and newborn health.

Pulmonary oedema in the course of severe maternal outcome in South Africa: A cohort study combined with clinical audit.

OBJECTIVES: To describe the incidence and outcomes of pulmonary oedema in women with severe maternal outcome during childbirth and identify possible modifiable factors through audit. METHODS: All women with severe maternal outcome (maternal deaths or near misses) who were referred to Tygerberg referral hospital from health facilities in Metro East district, South Africa, during 2014-2015 were included. Women with severe maternal outcome and pulmonary oedema during pregnancy or childbirth were evaluated using three types of critical incident audit: criterion-based case review by one consultant gynaecologist, monodisciplinary critical incident audit by a team of gynaecologists, multidisciplinary audit with expert review from anaesthesiologists and cardiologists. RESULTS: Of 32,161 pregnant women who gave birth in the study period, 399 (1.2%) women had severe maternal outcome and 72/399 (18.1%) had pulmonary oedema with a case fatality rate of 5.6% (4/72). Critical incident audit demonstrated that pre-eclampsia/HELLP-syndrome and chronic hypertension were the main conditions underlying pulmonary oedema (44/72, 61.1%). Administration of volumes of intravenous fluids in already sick women, undiagnosed underlying cardiac illness, administration of magnesium sulphate as part of pre-eclampsia management and oxytocin for augmentation of labour were identified as possible contributors to the pathophysiology of pulmonary oedema. Women-related factors (improved antenatal care attendance) and health care-related factors (earlier diagnosis and management) would potentially have improved maternal outcome. CONCLUSIONS: Although pulmonary oedema in pregnancy is rare, among women with severe maternal outcome a considerable proportion had pulmonary oedema (18.1%). Audit identified options for prevention of pulmonary oedema and improved outcome. These included early detection and management of preeclampsia with close monitoring of fluid intake and cardiac evaluation in case of suspected pulmonary oedema. Therefore, a multidisciplinary clinical approach is recommended.

The key role of examining the placenta in establishing a probable cause for stillbirth.

INTRODUCTION: Autopsy is regarded as the "gold standard" to determine probable causes of stillbirths. However, autopsy is expensive and not readily available in low- and middle-income countries. Therefore, we assessed how the clinical cause of death is modified by adding placental histology and autopsy findings. METHOD: Data from the Safe Passage Study was used where 7060 pregnant women were followed prospectively. Following a stillbirth, each case was discussed and classified at weekly perinatal mortality meetings. This classification was later adapted to the WHO ICD PM system. Clinical information was presented first, and a possible cause of death decided upon and noted. The placental histology was then presented and, again, a possible cause of death, using the placental and clinical information, was decided upon and noted, followed by autopsy information. Diagnoses were then compared to determine how often the additional information changed the initial clinical findings. RESULTS: Clinical information, placental histology, and autopsy results were available in 47 stillbirths. There were major amendments from the clinical only diagnoses when placental histology was added. Forty cases were classified as due to M1: complications of placenta, cord, and membranes, when placental histology was added compared to 7 cases with clinical classification only, and M5: No maternal condition identified decreased from 30 cases to 3 cases. Autopsy findings confirmed the clinical and placental histology findings. DISCUSSION: Clinical information together with examination of the placenta revealed sufficient information to diagnose the most probable cause of death in 40 of 47 cases of stillbirth (85%).

Cohort profile: the Western Cape Pregnancy Exposure Registry (WCPER).

PURPOSE: The Western Cape Pregnancy Exposure Registry (PER) was established at two public sector healthcare sentinel sites in the Western Cape province, South Africa, to provide ongoing surveillance of drug exposures in pregnancy and associations with pregnancy outcomes. PARTICIPANTS: Established in 2016, all women attending their first antenatal visit at primary care obstetric facilities were enrolled and followed to pregnancy outcome regardless of the site (ie, primary, secondary, tertiary facility). Routine operational obstetric and medical data are digitised from the clinical stationery at the healthcare facilities. Data collection has been integrated into existing services and information platforms and supports routine operations. The PER is situated within the Provincial Health Data Centre, an information exchange that harmonises and consolidates all health-related electronic data in the province. Data are contributed via linkage across a unique identifier. This relationship limits the missing data in the PER, allows validation and avoids misclassification in the population-level data set. FINDINGS TO DATE: Approximately 5000 and 3500 pregnant women enter the data set annually at the urban and rural sites, respectively. As of August 2021, >30 000 pregnancies have been recorded and outcomes have been determined for 93%. Analysis of key obstetric and neonatal health indicators derived from the PER are consistent with the aggregate data in the District Health Information System. FUTURE PLANS: This represents significant infrastructure, able to address clinical and epidemiological concerns in a low/middle-income setting.

Attachment and Its Impact over Three Generations.

BACKGROUND: Attachment parameters affect the development of self-concept and relationship patterns. However, studies on the impact of attachment parameters on symptoms of the offspring in childhood are still lacking. We therefore investigated the influence of attachment parameters of the grandparents on those of the parents treated in a psychiatric hospital, and finally on the symptoms of their (grand)children. Furthermore, the impact of attachment factors on parenting style and on resilience of parents and children has been examined. SUBJECTS AND METHODS: A sample of n=50 mother-child-dyads in an inpatient setting was examined using the questionnaires FEB (Questionnaire on the Parental Attachment; adult and child perspective), RQ2 (Relationship Questionnaire), EFB-K (Educational Questionnaire, short form), RS13 (Resilience Scale; adult and child perspective), and CBCL (Child Behavior Checklist). Regression analyses and correlation analyses were carried out. RESULTS: On grandparents' level, attachment patterns predicted parents' attachment patterns (p=0.012): Grandfather's care (control) behavior correlated with more (less) mother's care for their own children (0.002 (0.005)). Control behavior of the grandfather was negatively correlated with the resilience of their daughters (p=0.033). On parents' level, a secure attachment style predicted a less overreacting parenting style (p=0.004), whereas an anxious-avoiding (p=0.035) or clinging attachment style (p=0.044) predicted an increased overreacting parenting style. On child's level, mental (esp. attentional (p=0.013) and externalizing (p=0.032)) symptoms correlated negatively with the level of care reported by the mother. CONCLUSION: Functional attachment behavior at the grandparents' level correlated significantly with functional attachment behavior at the parental level, which in turn correlated with reduced mental symptoms at the child's level. The parenting style seems to play a mediator role for the development of attachment between mother and child, with resilience mediating between attachment and the onset of mental disorders. The results point to the crucial role of attachment parameters for mental development with corresponding implications for psychotherapy.

Maternal mortality: near-miss events in middle-income countries, a systematic review.

OBJECTIVE: To describe the incidence and main causes of maternal near-miss events in middle-income countries using the World Health Organization's (WHO) maternal near-miss tool and to evaluate its applicability in these settings. METHODS: We did a systematic review of studies on maternal near misses in middle-income countries published over 2009-2020. We extracted data on number of live births, number of maternal near misses, major causes of maternal near miss and most frequent organ dysfunction. We extracted, or calculated, the maternal near-miss ratio, maternal mortality ratio and mortality index. We also noted descriptions of researchers' experiences and modifications of the WHO tool for local use. FINDINGS: We included 69 studies from 26 countries (12 lower-middle- and 14 upper-middle-income countries). Studies reported a total of 50 552 maternal near misses out of 10 450 482 live births. Median number of cases of maternal near miss per 1000 live births was 15.9 (interquartile range, IQR: 8.9-34.7) in lower-middle- and 7.8 (IQR: 5.0-9.6) in upper-middle-income countries, with considerable variation between and within countries. The most frequent causes of near miss were obstetric haemorrhage in 19/40 studies in lower-middle-income countries and hypertensive disorders in 15/29 studies in upper-middle-income countries. Around half the studies recommended adaptations to the laboratory and management criteria to avoid underestimation of cases of near miss, as well as clearer guidance to avoid different interpretations of the tool. CONCLUSION: In several countries, adaptations of the WHO near-miss tool to the local context were suggested, possibly hampering international comparisons, but facilitating locally relevant audits to learn lessons.

Major obstetric haemorrhage in Metro East, Cape Town, South Africa: a population-based cohort study using the maternal near-miss approach.

BACKGROUND: Major obstetric haemorrhage is a leading cause of maternal mortality and accounts for one-third of maternal deaths in of Africa. This study aimed to assess the population-based incidence, causes, management and outcomes of major obstetric haemorrhage and risk factors associated with poor maternal outcome. METHODS: Women with major obstetric haemorrhage who met the WHO maternal near-miss criteria or died in the Metro East region, Cape Town, South Africa, were evaluated from November 2014-November 2015. Major obstetric haemorrhage was defined as haemorrhage in pregnancies of at least 20 weeks' gestation or occurring up to 42 days after birth, and leading to hysterectomy, hypovolaemic shock or blood transfusion of ≥5 units of Packed Red Blood Cells. A logistic regression model was used to analyse associations with poor outcome, defined as major obstetric haemorrhage leading to massive transfusion of ≥8 units of packed red blood cells, hysterectomy or death. RESULTS: The incidence of major obstetric haemorrhage was 3/1000 births, and the incidence of massive transfusion was 4/10.000 births in the Metro East region (32.862 births occurred during the studied time period). Leading causes of haemorrhage were placental abruption 45/119 (37.8%), complications of caesarean section 29/119 (24.4%) and uterine atony 13/119 (10.9%). Therapeutic oxytocin was administered in 98/119 (82.4%) women and hysterectomy performed in 33/119 (27.7%). The median numbers of packed red blood cells and units of Fresh Frozen Plasma transfused were 6 (interquartile range 4-7) and 3 (interquartile range 2-4), ratio 1.7:1. Caesarean section was independently associated with poor maternal outcome: adjusted OR 4.01 [95% CI 1.58, 10.14]. CONCLUSIONS: Assessment of major obstetric haemorrhage using the Maternal Near Miss approach revealed that placental abruption and complications of caesarean section were the major causes of major obstetric haemorrhage. Caesarean section was associated with poor outcome.

Effects of Prodromal Stage and Untreated Psychosis on Subsequent Psychopathology of Schizophrenia: A Path Analysis.

BACKGROUND: To examine psychopathology present under prolonged antipsychotic treatment in schizophrenia and to analyse their relationship to both the duration of the prodromal stage (DPS; time between onset of first unspecific psychological symptoms and first schizophrenic symptoms) and the duration of untreated psychosis (DUP; time between the onset of psychosis and the initiation of antipsychotic treatment). METHODS: The psychopathology of 93 patients was assessed cross-sectionally using the Scales for the Assessment of Negative and Positive Symptoms and the Brief Psychiatric Rating Scale. DPS and DUP were assessed by means of the patient records and the Interview for the Retrospective Assessment of the Onset and Course of Schizophrenia and Other Psychoses. A path analysis using maximum likelihood estimation was conducted with the program Analysis of Moment Structures for Windows. RESULTS: The resulting path model indicated that DPS was predictive for a more severe negative symptomatology in schizophrenia, whereas DUP was associated with a more severe positive symptomatology in the long-term. Furthermore, DUP showed an inverse correlation with the age of the patients at the onset of both first unspecific psychological symptoms and first schizophrenic symptoms. CONCLUSION: A long prodromal stage suggests an increased risk of a long-term progression with negative symptoms in schizophrenia, whereas a delayed start of antipsychotic treatment could lead to an increased manifestation and severity of positive symptoms in the long term. These results underline the need to shorten the duration of the prodrome by an early detection and adequate intervention in patients with increased risk to develop psychosis.

A district-wide population-based descriptive study of emergency peripartum hysterectomy in a middle-income country.

OBJECTIVE: To determine incidence, risk indicators, and outcomes of emergency peripartum hysterectomy (EPH) in Metro East, Cape Town, South Africa. METHODS: A population-based district-wide prospective descriptive study of EPH in public hospitals from November 2014 to November 2015. Women were enrolled by using the WHO maternal near miss tool and followed until discharge. EPH was defined as hemorrhage or infection leading to hysterectomy during pregnancy or within 42 days of delivery. RESULTS: Fifty-nine women experienced EPH with an overall incidence of 14.3 per 10 000 women: 32 procedures were for postpartum hemorrhage, 27 for puerperal sepsis. Two women died: one from sepsis; one from hemorrhage. Overall, 51 (86%) women delivered by cesarean, and 23/51 (45%) by repeat cesarean. As compared with hemorrhage, EPH for sepsis involved older women (mean age, 31.5 vs 24.4 years) and those with higher gravidity (median, 3 vs 1), and was associated with longer hospital admission (median, 11.5 vs 4 days), with occurrence later postpartum (median, 8 vs 0 days), and more frequently with complications. CONCLUSIONS: The incidence of EPH for sepsis was higher than previously reported. Repeat cesarean was strongly associated with EPH. Clinical characteristics of sepsis-related EPH compared unfavorably with those of hemorrhage-related EPH.

The impact of attachment parameters in childhood on the personality of adults with mental disorders.

BACKGROUND: Attachment parameters have an effect on later relationship patterns and the development of parameters of self-concept and personality. In the current study the role of attachment parameters on personality dimensions was investigated, especially with respect to personality disorders. SUBJECTS AND METHODS: 134 psychiatric inpatients were examined on attachment and personality parameters using the schedule FEB as a questionnaire on the parental attachment and the SKI as a self-concept inventory. RESULTS: Regression and correlation analyses suggest positive influences of parental care and negative influences of parental overprotection on the development of ego-strength in adulthood. Patients with personality disorders reported to have experienced less maternal care during their childhood and showed a trend towards a reduced ego-strength in adulthood compared to patients with others mental disorders. CONCLUSIONS: Relationships of attachment parameters in childhood with personality dimension are explorable. This approach seems meaningful for a better understanding of the development of personality disorders. Clinicians should be familiar with attachment patterns when treating people with mental disorders in order to adequately include appropriate personality dimensions in the therapy.

Standardized outcome measures for pregnancy and childbirth, an ICHOM proposal.

BACKGROUND: Value-based health care aims to optimize the balance of patient outcomes and health care costs. To improve value in perinatal care using this strategy, standard outcomes must first be defined. The objective of this work was to define a minimum, internationally appropriate set of outcome measures for evaluating and improving perinatal care with a focus on outcomes that matter to women and their families. METHODS: An interdisciplinary and international Working Group was assembled. Existing literature and current measurement initiatives were reviewed. Serial guided discussions and validation surveys provided consumer input. A series of nine teleconferences, incorporating a modified Delphi process, were held to reach consensus on the proposed Standard Set. RESULTS: The Working Group selected 24 outcome measures to evaluate care during pregnancy and up to 6 months postpartum. These include clinical outcomes such as maternal and neonatal mortality and morbidity, stillbirth, preterm birth, birth injury and patient-reported outcome measures (PROMs) that assess health-related quality of life (HRQoL), mental health, mother-infant bonding, confidence and success with breastfeeding, incontinence, and satisfaction with care and birth experience. To support analysis of these outcome measures, pertinent baseline characteristics and risk factor metrics were also defined. CONCLUSIONS: We propose a set of outcome measures for evaluating the care that women and infants receive during pregnancy and the postpartum period. While validation and refinement via pilot implementation projects are needed, we view this as an important initial step towards value-based improvements in care.

The effects of music therapy on the interaction of the self and emotions-An interim analysis.

OBJECTIVES: Music therapy is a well-established non-verbal treatment method in psychiatry and psychosomatic medicine. However, empirical data of its impact on emotion modulation processes and personality dimensions are still sparce. An interesting concept is the use of music for emotion modulation in everyday life. The purpose of this interim study was to assess the interplay of personality dimensions and emotion modulation strategies in patients treated with music therapy versus patients without music therapy. DESIGN: A cross-sectional design was used. SETTING: The study was conducted during the course of inpatient treatment in a general psychiatric hospital. Data from n = 137 patients was included in the analysis. MAIN OUTCOME MEASURES: According to the mediator model a regression analysis was performed using personality variables as potential predictors and emotion modulation variables as outcome criteria. RESULTS: In the music therapy group, insecurity predicted the use of music for both cognitive problem solving and positive stimulation in everyday life. In the non-music therapy group, cooperation and insouciance predicted the use of music for reduction of negative activation. CONCLUSIONS: Specific personality dimensions predict greater targeted emotion modulation strategies if music therapy is applied than without it. That is, music therapy helps patients acquire more conscious (i.e. cognitive-related strategies) emotion modulation techniques by means of including their individual personality, whereas patients without music therapy simply "vent" their negative emotions (i.e. non-cognitive strategies). Conversely, the data suggest that music therapy can contribute to modify personality dimensions through the development of these emotion modulation strategies. This could be a plausible explanation for beneficial long-term effects of music therapy.

Pain Relief in Depressive Disorders: A Meta-Analysis of the Effects of Antidepressants.

BACKGROUND: Pain is a common symptom in patients with depressive disorders, which, if present, worsens the prognosis. However, there is little empirical knowledge of the therapeutic effects of antidepressants on painful physical symptoms of patients with depressive disorders. Furthermore, tricyclic/tetracyclic antidepressants (TCAs) have not yet been included in existing meta-analyses. METHODS: A broad, systematic search of PubMed literature on antidepressant drug treatment of patients with depressive disorders with comorbid pain symptoms was carried out. A random-effects meta-analysis has been performed among 3 different groups of drugs for the 2 end points: pain and depression. RESULTS: Fourteen placebo-controlled studies with selective serotonin-noradrenaline reuptake inhibitors (SSNRIs) could be included, with 3 of them also investigating selective serotonin reuptake inhibitors (SSRIs). Three further placebo-controlled SSRI studies were identified, but only 2 placebo-controlled TCA studies.Both SSNRIs and SSRIs, but not TCAs, were significantly superior to placebo as regards their analgesic effects. However, all effects were small. For SSNRIs, there was a strong positive correlation between their effectiveness for pain relief and their positive effect on the mood of the patients. DISCUSSION: The analgesic effects of SSNRIs and SSRIs in patients with primary depressive disorders can be interpreted as largely equivalent. Because of a lack of placebo-controlled TCA studies, the results for TCAs would be comparable only to those of SSRIs and SSNRIs, if non-placebo-controlled TCA studies were included. The positive correlation found indicates a close relationship of pain relief and antidepressant treatment effects. These results refer merely to patients with primary depressive disorders, not to patients with primary pain disorders. Further studies comparing the effects of different types of antidepressant drugs on pain in depressive patients are warranted.

What Influences Treatment Satisfaction in Patients with Personality Disorders? A Naturalistic Investigation in a Hospitalization Setting.

Treatment satisfaction of different mental disorders is still poorly understood, but of high clinical interest. Inpatients of a general psychiatric care hospital were asked to fill out questionnaires on satisfaction and clinical variables at admission and discharge. On the basis of an exploratory approach, differences in treatment satisfaction among diagnostic groups were examined by means of one-way analysis of variance. Potential associated clinical and socio-demographic variables were studied using multi/univariate tests. Patients with personality disorders (n=18) showed a significantly lower treatment satisfaction (ZUF-8, Zurich Satisfaction Questionnaire) and a slightly lower improvement of symptoms (CGI, Clinical Global Impression) and global functioning (GAF, Global Assessment of Functioning scale) than that of other diagnostic groups (n=95). Satisfaction in patients with personality disorders correlated much stronger with the symptom improvement and slightly with the functioning level than in patients without personality disorders. Interestingly, in patients with personality disorders psychopharmacological treatment in general (present versus not present) was independent from satisfaction. This exploratory investigation suggests that a lower satisfaction of patients with personality disorders in a general psychiatric hospital is mainly based on a reduced improvement of the symptoms and of the global functioning level.

Introducing a Mobile-Connected Umbilical Doppler Device (UmbiFlow™) into a Primary Care Maternity Setting: Does This Reduce Unnecessary Referrals to Specialised Care? Results of a Pilot Study in Kraaifontein, South Africa.

OBJECTIVES: UmbiFlow™ is a mobile-connected Doppler device that utilises a continuous waveform to measure resistance in the umbilical artery. The main aim of this pilot study was to determine whether the use of UmbiFlow™ for umbilical artery Doppler in patients with a suspected decreased symphysis fundal (SF) growth could safely lead to a decreased number of patients requiring referral to a more specialised level of care. A secondary aim of the study was to evaluate the effectiveness of UmbiFlow™ Doppler as a screening tool for concealed placental insufficiency in late bookers by using a single screening cut-off value that will be abnormal for any gestation >28 weeks. METHODS: The cohort comprised two groups of patients: The first group included all follow-up patients with suspected intra-uterine growth restriction (a decreased symphysis-fundus measurement based on serial assessment) who underwent on-site UmbiFlow™Doppler testing performed by the midwife directly after the clinical examination. The second group included late bookers, where gestation was uncertain; but estimated >28 weeks based on clinical grounds. This group was comprised of unselected patients who report to antenatal care late for the first time and received an UmbiFlow™Doppler test for concealed placental insufficiency. RESULTS: UmbiFlow™Doppler could reduce the number of false referrals to hospital by 55%. A single UmbiFlow™Doppler test in late bookers appeared to identify a group of women at moderate risk of lower birth weight babies.

The Change of Music Preferences Following the Onset of a Mental Disorder.

A psychiatric population (n=123) was examined on how music preferences had changed after the onset of a mental disorder. Most patients did not change their previous music preference; this group of patients considered music helpful for their mental state, showed more attractivity and enforcement as personality traits and used music more for emotion modulation. Patients who experienced a preference shift reported that music had impaired them during the time of illness; these patients showed less ego-strength, less confidence and less enforcement and used music less for arousal modulation. A third subgroup stopped listening to music completely after the onset of the mental disorder; these patients attribute less importance to music and also reported that music had impaired their mental state. They showed more ego-strength and used music less for emotion modulation. The results suggest that the use of music in everyday life can be helpful as an emotion modulation strategy. However, some patients might need instructions on how to use music in a functional way and not a dysfunctional one. Psychiatrists and psychotherapists as well as music therapists should be aware of emotion modulation strategies, subjective valence of music and personality traits of their patients. Due to the ubiquity of music, psychoeducative instructions on how to use music in everyday life plays an increasing role in the treatment of mental illness.

Elective Delivery at Term after a Previous Unexplained Intra-Uterine Fetal Death: Audit of Delivery Outcome at Tygerberg Hospital, South Africa.

OBJECTIVES: To assess the delivery outcome in a pregnancy with a previous unexplained intra-uterine death by elective induction of labour at term. METHODS: An audit of the pregnancy outcome of all women within the catchment area with a current singleton pregnancy; and a previous unexplained or unexplored singleton fetal demise ≥24 weeks (or 500 grams birth weight if gestation unknown) after planned routine induction of labour at full term (39-40 weeks). RESULTS: During the audit period, 306 patients with a previous intra-uterine fetal death were referred for further management. Of these, 161 had a clear indication for earlier intervention and were excluded from the protocol. Of the remaining 145 patients, 9 met further exclusion criteria and there were 2 patients who defaulted. Forty-two of the remaining study patients (with no known previous medical problems) developed complications during their antenatal course that necessitated a change in clinical management and earlier (<39 weeks) delivery. Of the remaining 92 patients in the audit, 47 (51%) went into spontaneous labour before their induction date; all 92 women delivered without major complications. There were no intra-uterine deaths prior to induction. CONCLUSIONS: Careful follow up at a high risk clinic identifies new or concealed maternal or fetal complications in 29% of patients with a previous intra-uterine death and no obvious maternal or fetal disease in the index pregnancy. When all risks are excluded and the pregnancy allowed to progress to full term (39-40 weeks) before an induction is offered, 50% will go into spontaneous labour.