Guideline nº 431: postpartum hemorrhage and hemorrhagic shock

This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock. Benefits, harms, and costs Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays. Medical literature, PubMed, ClinicalTrials.gov, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists.

Inclusive, supportive and dignified maternity care (SDMC)-Development and feasibility assessment of an intervention package for public health systems: A study protocol.

INTRODUCTION: Mistreatment, discrimination, and poor psycho-social support during childbirth at health facilities are common in lower- and middle-income countries. Despite a policy directive from the World Health Organisation (WHO), no operational model exists that effectively demonstrates incorporation of these guidelines in routine facility-based maternity services. This early-phase implementation research aims to develop, implement, and test the feasibility of a service-delivery strategy to promote the culture of supportive and dignified maternity care (SDMC) at public health facilities. METHODS: Guided by human-centred design approach, the implementation of this study will be divided into two phases: development of intervention, and implementing and testing feasibility. The service-delivery intervention will be co-created along with relevant stakeholders and informed by contextual evidence that is generated through formative research. It will include capacity-building of maternity teams, and the improvement of governance and accountability mechanisms within public health facilities. The technical content will be primarily based on WHO's intrapartum care guidelines and mental health Gap Action Programme (mhGAP) materials. A mixed-method, pre-post design will be used for feasibility assessment. The intervention will be implemented at six secondary-level healthcare facilities in two districts of southern Sindh, Pakistan. Data from multiple sources will be collected before, during and after the implementation of the intervention. We will assess the coverage of the intervention, challenges faced, and changes in maternity teams' understanding and attitude towards SDMC. Additionally, women's maternity experiences and psycho-social well-being-will inform the success of the intervention. EXPECTED OUTCOMES: Evidence from this implementation research will enhance understanding of health systems challenges and opportunities around SDMC. A key output from this research will be the SDMC service-delivery package, comprising a comprehensive training package (on inclusive, supportive and dignified maternity care) and a field tested strategy to ensure implementation of recommended practices in routine, facility-based maternity care. Adaptation, Implementation and evaluation of SDMC package in diverse setting will be way forward. The study has been registered with clinicaltrials.gov (Registration number: NCT05146518).

"Even though they insult us, the delivery they give us is the greatest thing": a qualitative study contextualizing women's experiences with facility-based maternal health care in Ethiopia.

BACKGROUND: Globally, amidst increased utilization of facility-based maternal care services, there is continued need to better understand women's experience of care in places of birth. Quantitative surveys may not sufficiently characterize satisfaction with maternal healthcare (MHC) in local context, limiting their interpretation and applicability. The purpose of this study is to untangle how contextual and cultural expectations shape women's care experience and what women mean by satisfaction in two Ethiopian regions. METHODS: Health center and hospital childbirth care registries were used to identify and interview 41 women who had delivered a live newborn within a six-month period. We used a semi-structured interview guide informed by the Donabedian framework to elicit women's experiences with MHC and delivery, any prior delivery experiences, and recommendations to improve MHC. We used an inductive analytical approach to compare and contrast MHC processes, experiences, and satisfaction. RESULTS: Maternal and newborn survival and safety were central to women's descriptions of their MHC experiences. Women nearly exclusively described healthy and safe deliveries with healthy outcomes as 'satisfactory'. The texture behind this 'satisfaction', however, was shaped by what mothers bring to their delivery experiences, creating expectations from events including past births, experiences with antenatal care, and social and community influences. Secondary to the absence of adverse outcomes, health provider's interpersonal behaviors (e.g., supportive communication and behavioral demonstrations of commitment to their births) and the facility's amenities (e.g., bathing, cleaning, water, coffee, etc) enhanced women's experiences. Finally, at the social and community levels, we found that family support and material resources may significantly buffer against negative experiences and facilitate women's overall satisfaction, even in the context of poor-quality facilities and limited resources. CONCLUSION: Our findings highlight the importance of understanding contextual factors including past experiences, expectations, and social support that influence perceived quality of MHC and the agency a woman has to negotiate her care experience. Our finding that newborn and maternal survival primarily drove women's satisfaction suggests that quantitative assessments conducted shortly following delivery may be overly influenced by these outcomes and not fully capture the complexity of women's care experience.

Do high-deductible health plans affect price paid for childbirth?

OBJECTIVE: To test whether out-of-pocket costs and negotiated hospital prices for childbirth change after enrollment in high-deductible health plans (HDHPs) and whether price effects differ in markets with more hospitals. DATA SOURCES: Administrative medical claims data from 2010 to 2014 from three large commercial insurers with plans in all U.S. states provided by the Health Care Cost Institute (HCCI). STUDY DESIGN: I identify employer groups that switched from non-HDHPs in 1 year to HDHPs in a subsequent year. I estimate enrollees' change in out-of-pocket costs and negotiated hospital prices for childbirth after HDHP switch, relative to a comparison group of employers that do not switch plans. I use a triple-difference design to estimate price changes for enrollees in markets with more hospital choices. Finally, I re-estimate models with hospital-fixed effects. DATA COLLECTION: From the HCCI sample, childbearing women enrolled in an employer-sponsored plan with at least 10 people. PRINCIPAL FINDINGS: Switching to an HDHP increases out-of-pocket cost $227 (p < 0.001; comparison group base $790) and has no meaningful effect on hospital-negotiated prices (-$26, p = 0.756; comparison group base $5821). HDHP switch is associated with a marginally statistically significant price increase in markets with three or fewer hospitals ($343, p = 0.096; comparison group base $5806) and, relative to those markets, with a price decrease in markets with more than three hospitals (-$512; p = 0.028). Predicted prices decrease from $5702 to $5551 after HDHP switch in markets with more than three hospitals due primarily to lower prices conditional on using the same hospital. CONCLUSIONS: Prices for childbirth in markets with more hospitals decrease after HDHP switch due to lower hospital prices for HDHPs relative to prices at those same hospitals for non-HDHPs. These results reinforce previous findings that HDHPs do not promote price shopping but suggest negotiated prices may be lower for HDHP enrollees.

Effects of the World Health Organization Safe Childbirth Checklist on Quality of Care and Birth Outcomes in Aceh, Indonesia: A Cluster-Randomized Clinical Trial.

Importance: To address major causes of perinatal and maternal mortality, the World Health Organization developed the Safe Childbirth Checklist (SCC), which to our knowledge has been rigorously evaluated only in combination with high-intensity coaching. Objective: To evaluate the effect of the SCC with medium-intensity coaching on health care workers' performance of essential birth practices. Design, Setting, and Participants: This cluster randomized clinical trial without blinding included 32 hospitals and community health centers in the province of Aceh, Indonesia (a medium-resource setting) that met the criterion of providing at least basic emergency obstetric and newborn care. Baseline data were collected from August to October 2016, and outcomes were measured from March to April 2017. Data were analyzed from January 2020 to October 2021. Interventions: After applying an optimization method, facilities were randomly assigned to the treatment or control group (16 facilities each). The SCC with 11 coaching visits was implemented during a 6-month period. Main Outcomes and Measures: For the primary outcome, clinical observers documented whether 36 essential birth practices were applied at treatment and control facilities at 1 or more of 4 pause points during the birthing process (admission to the hospital, just before pushing or cesarean delivery, soon after birth, and before hospital discharge). Probability models for binary outcome measures were estimated using ordinary least-squares regressions, complemented by Firth logit and complier average causal effect estimations. Results: Among the 32 facilities that participated in the trial, a significant increase of up to 41 percentage points was observed in the application of 5 of 36 essential birth practices in the 16 treatment facilities compared with the 16 control facilities, including communication of danger signs at admission (treatment: 136 of 155 births [88%]; control: 79 of 107 births [74%]), measurement of neonatal temperature (treatment: 9 of 31 births [29%]; control: 1 of 20 births [5%]), newborn feeding checks (treatment: 22 of 34 births [65%]; control: 5 of 21 births [24%]), and the rate of communication of danger signs to mothers and birth companions verbally (treatment: 30 of 36 births [83%]; control: 14 of 22 births [64%]) and in a written format (treatment: 3 of 24 births [13%]; control: 0 of 16 births [0%]). Conclusions and Relevance: In this cluster randomized clinical trial, health facilities that implemented the SCC with medium-intensity coaching had an increased rate of application for 5 of 36 essential birth practices compared with the control facilities. Medium-intensity coaching may not be sufficient to increase uptake of the SCC to a satisfying extent, but it may be worthwhile to assess a redesigned coaching approach prompting long-term behavioral change and, therefore, effectiveness. Trial Registration: isrctn.org Identifier: ISRCTN11041580.

Midwives' perspectives on person-centred maternity care in public hospitals in South-east Nigeria: A mixed-method study.

BACKGROUND: Person-centred maternity care (PCMC) is acknowledged as essential for achieving improved quality of care during labour and childbirth. Yet, evidence of healthcare providers' perspectives of person-centred maternity care is scarce in Nigeria. This study, therefore, examined the perceptions of midwives on person-centred maternity care (PCMC) in Enugu State, South-east Nigeria. MATERIALS AND METHODS: This study was conducted in seven public hospitals in Enugu metropolis, Enugu State, South-east Nigeria. A mixed-methods design, involving a cross-sectional survey and focus group discussions (FGDs) was used. All midwives (n = 201) working in the maternity sections of the selected hospitals were sampled. Data were collected from February to May 2019 using a self-administered, validated PCMC questionnaire. A sub-set of midwives (n = 56), purposively selected using maximum variation sampling, participated in the FGDs (n = 7). Quantitative data were entered, cleaned, and analysed with SPSS version 20 using descriptive and bivariate statistics and multivariate regression. Statistical significance was set at alpha 0.05 level. Qualitative data were analysed thematically. RESULTS: The mean age of midwives was 41.8 years ±9.6 years. About 53% of midwives have worked for ≥10 years, while 60% are junior midwives. Overall, the prevalence of low, medium, and high PCMC among midwives were 26%, 49% and 25%. The mean PCMC score was 54.06 (10.99). High perception of PCMC subscales ranged from 6.5% (dignity and respect) to 19% (supportive care). Midwives' perceived PCMC was not significantly related to any socio-demographic characteristics. Respectful care, empathetic caregiving, prompt initiation of care, paying attention to women, psychosocial support, trust, and altruism enhanced PCMC. In contrast, verbal and physical abuses were common but normalised. Midwives' weakest components of autonomy and communication were low involvement of women in decision about their care and choice of birthing position. Supportive care was constrained by restrictive policy on birth companion, poor working conditions, and cost of childbirth care. CONCLUSION: PCMC is inadequate in public hospitals as seen from midwives' perspectives. Demographic characteristics of midwives do not seem to play a significant role in midwives' delivery of PCMC. The study identified areas where midwives must build competencies to deliver PCMC.

Effect of decision to delivery interval on perinatal outcomes during emergency cesarean deliveries in Ethiopia: A prospective cohort study.

BACKGROUND: The National guidelines of most developed countries suggest a target of 30 minutes of the decision to delivery interval for emergency cesarean section. Such guidelines may not be feasible in poorly resourced countries and busy obstetric settings. It is generally accepted that the decision to delivery interval should be kept to the minimum time achievable to prevent adverse outcomes. Therefore, this study aimed to determine the average decision to delivery interval and its effect on perinatal outcomes in emergency cesarean section. METHODS: A prospective cohort study was conducted from May to July 2020 at Bahir Dar City Public Hospitals. A total of 182 participants were enrolled, and data were collected using a structured and pre-tested questionnaire. A systematic sampling technique was applied to select the study subjects. Data were cleaned and entered into Epi-Data version 4.6 and exported to SPSS version 25 software for analysis. Logistic regression analysis was performed to identify predictors of outcome variables, and variables with a p-value of <0.05 were considered statistically significant. RESULTS: The average decision to delivery interval was 43.73 ±10.55 minutes. Anesthesia time [AOR = 2.1, 95%CI = (1.3-8.4)], and category of emergency cesarean section [AOR = 3, 95% CI = (2.1-11.5)] were predictors of decision to delivery interval. The prolonged decision to delivery interval had a statistically significant association with composite adverse perinatal outcomes (odds ratio [OR] = 1.8, 95% confidence interval [CI] = (1.2-6.5). CONCLUSION: The average decision to delivery interval was longer than the recommended time. It should always be considered an important factor contributing to perinatal outcomes. Therefore, to prevent neonatal morbidity and mortality, a time-dependent action is needed.

Consistency and timeliness of intrapartum care interventions as predictors of intrapartum stillbirth in public health facilities of Addis Ababa, Ethiopia: a case-control study.

INTRODUCTION: approximately one-third of the global stillbirth burden occurs during intrapartum period. Intrapartum stillbirths occurring in the health facilities imply that a foetus was alive on admission to labour and had greater chances of survival with optimum obstetric care. Active monitoring and follow-up by skilled birth attendants becomes critical to determine the progress of labour and to decide any emergency obstetrical care actions. Timely monitoring of labour progress indicators including fetal heart rate (FHR), uterine contraction maternal vital signs, vaginal examination (VE) are vital in reducing intrapartum stillbirth. METHODS: a case-control study was conducted using primary data from chart review of medical records of women who experienced intrapartum stillbirth in 20 public health centres and 3 public hospitals of Addis Ababa between July 1st, 2010 to June 30th, 2015. Data were collected from charts of all cases of intrapartum stillbirths meeting the inclusion criteria and randomly selected charts of controls from each public health facility in 2: 1 control to case ratio. RESULTS: over 90% of both cases and controls received FHR monitoring care albeit the timing was substandard. More women in the live birth group than intrapartum stillbirth group received timely care related to uterine contraction (OR 2.42, 95% CI 1.77 - 3.30) and blood pressure monitoring (aOR 1.41, 95% CI 1.09 - 1.81). 1.2% and 0.3% of women in the intrapartum stillbirth and livebirth groups developed eclampsia respectively. CONCLUSION: substandard timing and application of labour monitoring interventions including FHR, uterine contraction can predict intrapartum stillbirth in public health facilities.

Coexistence and prevalence of obstetric interventions: an analysis based on the grade of membership.

BACKGROUND: Obstetric interventions performed during delivery do not reflect improvements in obstetric care. Several practices routinely performed during childbirth, without any scientific evidence or basis - such as Kristeller maneuver, routine episiotomy, and movement or feeding restriction - reflect a disrespectful assistance reality that, unfortunately, remains in place in Brazil. The aims of the current study are to assess the coexistence and prevalence of obstetric interventions in maternity hospitals in Belo Horizonte City, based on the Grade of Membership (GoM) method, as well as to investigate sociodemographic and obstetric factors associated with coexistence profiles generated by it. METHODS: Observational study, based on a cross-sectional design, carried out with data deriving from the study "Nascer em Belo Horizonte: Inquérito sobre o Parto e Nascimento" (Born in Belo Horizonte: Survey on Childbirth and Birth). The herein investigated interventions comprised practices that are clearly useful and should be encouraged; practices that are clearly harmful or ineffective and should be eliminated; and practices that are inappropriately used, in contrast to the ones recommended by the World Health Organization. The analyzed interventions comprised: providing food to parturient women, allowing them to have freedom to move, use of partogram, adopting non-pharmacological methods for pain relief, enema, perineal shaving, lying patients down for delivery, Kristeller maneuver, amniotomy, oxytocin infusion, analgesia and episiotomy. The current study has used GoM to identify the coexistence of the adopted obstetric interventions. Variables such as age, schooling, skin color, primigravida, place-of-delivery financing, number of prenatal consultations, gestational age at delivery, presence of obstetric nurse at delivery time, paid work and presence of companion during delivery were taken into consideration at the time to build patients' profile. RESULTS: Results have highlighted two antagonistic obstetric profiles, namely: profile 1 comprised parturient women who were offered diet, freedom to move, use of partogram, using non-pharmacological methods for pain relief, giving birth in lying position, patients who were not subjected to Kristeller maneuver, episiotomy or amniotomy, women did not receive oxytocin infusion, and analgesia using. Profile 2, in its turn, comprised parturient women who were not offered diet, who were not allowed to have freedom to move, as well as who did not use the partograph or who were subjected to non-pharmacological methods for pain relief. They were subjected to enema, perineal shaving, Kristeller maneuver, amniotomy and oxytocin infusion. In addition, they underwent analgesia and episiotomy. This outcome emphasizes the persistence of an obstetric care model that is not based on scientific evidence. Based on the analysis of factors that influenced the coexistence of obstetric interventions, the presence of obstetric nurses in the healthcare practice has reduced the likelihood of parturient women to belong to profile 2. In addition, childbirth events that took place in public institutions have reduced the likelihood of parturient women to belong to profile 2. CONCLUSION(S): Based on the analysis of factors that influenced the coexistence of obstetric interventions, financing the hospital for childbirth has increased the likelihood of parturient women to belong to profile 2. However, the likelihood of parturient women to belong to profile 2 has decreased when hospitals had an active obstetric nurse at the delivery room. The current study has contributed to discussions about obstetric interventions, as well as to improve childbirth assistance models. In addition, it has emphasized the need of developing strategies focused on adherence to, and implementation of, assistance models based on scientific evidence.

Safe birth matters: facilitators and barriers to uptake of the WHO safe childbirth checklist tool in a Tanzania Regional Hospital.

BACKGROUND: The World Health Organization (WHO) developed the Safe Birth Checklist (SCC) to facilitate best practices in safe birthing practices. The SCC is utilizing existing evidence-based WHO guidelines and recommendations which has combined those into a single and practical bedside tool. The SCC is the first checklist-based intervention to target the prevention of maternal and neonatal deaths. OBJECTIVE: The objective of this project was to pilot-test the World Health Organization Safe Childbirth Checklist with Maternity Regional Hospital in, Tanzania. STUDY DESIGN AND METHODS: Retrospective analysis on 35 charts were completed to identify presence or absence of documentation aligned with evidenced based checklist items. Staff training, end user observations and focus group discussions were utilized to elicit feedback about the tool and the process. Descriptive statistics and manual content analysis were used to analyze the rate of uptake and ownership over the checklist. The Checklist is broken down into four sections or time points (that are considered natural pause points in the care of laboring women). The four different pause points are admission, delivery, post-partum, and discharge. RESULTS: We trained 26 participants out of 32 staff how to use the SCC. Delivery time point had the lowest at SCC completion rate at 39% compared to discharge having the highest completion rate at 93%. There was variation in completion rate of the checklist items at each time point. Checklist items at the beginning of each time point were completed between 94% and 100% of the time with the latter checklist list items completed between 29% and 57% of the time. CONCLUSION: This project was able to identify facilitators and potential barriers to the successful uptake of the Safe Childbirth Checklist in Shinyanga Regional Hospital. Based on these findings, the MOH have opportunities to utilize those findings in the scale-up of the implementation of the checklist and future evaluation activities.

Modification of oxytocin use through a coaching-based intervention based on the WHO Safe Childbirth Checklist in Uttar Pradesh, India: a secondary analysis of a cluster randomised controlled trial.

OBJECTIVE: To understand the prevalence of intrapartum oxytocin use, assess associated perinatal and maternal outcomes, and evaluate the impact of a WHO Safe Childbirth Checklist intervention on oxytocin use at primary-level facilities in Uttar Pradesh, India. DESIGN: Secondary analysis of a cluster-randomised controlled trial. SETTING: Thirty Primary and Community public health facilities in Uttar Pradesh, India from 2014 to 2017. POPULATION: Women admitted to a study facility for childbirth at baseline, 2, 6 or 12 months after intervention initiation. METHODS: The BetterBirth intervention aimed to increase adherence to the WHO Safe Childbirth Checklist. We used Rao-Scott Chi-square tests to compare (1) timing of oxytocin use between study arms and (2) perinatal mortality and resuscitation of infants whose mothers received intrapartum oxytocin versus who did not. MAIN OUTCOME MEASURES: Intrapartum and postpartum oxytocin administration, perinatal mortality, use of neonatal bag and mask. RESULTS: We observed 5484 deliveries. At baseline, intrapartum oxytocin was administered to 78.2% of women. Two months after intervention initiation, intrapartum oxytocin (I) was administered to 32.1% of women compared with 70.6% in the control (C) (P < 0.01); this difference diminished after the end of the intervention (I = 48.2%, C = 74.7%, P = 0.03). Partograph use remained at <1% at all facilities. Resuscitation was performed on 7.5% of infants whose mother received intrapartum oxytocin versus 2.0% who did not (P < 0.0001). CONCLUSIONS: In this setting, intrapartum oxytocin use was high despite limited maternal/fetal monitoring or caesarean capability, and was associated with increased neonatal resuscitation. The BetterBirth intervention was successful at decreasing intrapartum oxytocin use. Ongoing support is needed to sustain these practices. TWEETABLE ABSTRACT: Coaching + WHO Safe Childbirth Checklist reduces intrapartum oxytocin use and need for newborn resuscitation.

The increasing use of the WHO Safe Childbirth Checklist: lessons learned at the Yaoundé Gynaeco-Obstetric and Paediatric Hospital, Cameroon.

BACKGROUND: Safe childbirth remains a daunting challenge, particularly in low-middle income countries, where most pregnancy-related deaths occur. Cameroon's maternal mortality rate, estimated at 529 per 100,000 live births in 2017, is significantly high. The WHO Safe Childbirth Checklist (SCC) was designed to improve the quality of care provided to pregnant women during childbirth. The SCC was implemented at the Yaoundé Gynaeco-Obstetric and Paediatric Hospital to improve the quality of care during childbirth. METHODS: This study was a retrospective study to determine the adoption rate of the SCC and its association with maternal (eclampsia, perineal tears, and postpartum haemorrhage) and neonatal (stillbirth, neonatal asphyxia and neonatal death) complications. Data were collected 6 months after the introduction of the SCC. Multivariate binary logistic regression was used to analyse the association between the use of the SCC and maternofoetal complications. RESULTS: Out of 1611 deliveries conducted, 1001 records were found, giving a retrieval rate of 62%. Twenty-five records were excluded. During the study period, the checklists were used in 828 of 976 clinical notes, with an adoption rate of 84.8% and a utilization rate of 93.9% at 6 months. Severe preeclampsia/eclampsia was associated with the non-use of the SCC (2.1 vs 5.4%, p = 0.041). Stillbirth, neonatal asphyxia, and neonatal death rates were not significantly different between the checklist and non-checklist groups. However, for all neonatal outcomes, the proportion of complications was lower when the checklist was used. CONCLUSION: The use of the SCC was associated with significantly reduced pregnancy complications, especially for reducing the rates of severe pre-eclampsia/eclampsia. The use of the SCC increased to 93.9% of all deliveries within 6 months. We advocate for the use of the WHO Safe Childbirth Checklist in maternity units.

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

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

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

Facility-level determinants of quality routine intrapartum care in Afghanistan.

BACKGROUND: Although there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan. METHODS: We analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores. RESULTS: Across 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care. CONCLUSIONS: Quality of routine intrapartum care at health facilities in Afghanistan is concerningly low. Our analysis suggests that multi-faceted interventions are needed to address direct and indirect contributors to quality of care including clinical care practices, attention to client experiences during labor and childbirth, and attention to staff welfare and opportunities, including gender equality within the health workforce.

Quality of vital sign monitoring during obstetric hospitalizations at a regional referral and teaching hospital in Uganda: an opportunity for improvement.

INTRODUCTION: vital sign monitoring is a key component of safe facility-based obstetric care. We aimed to assess quality of care around vital sign monitoring during obstetric hospitalizations in a tertiary-care facility in a resource-limited setting. METHODS: retrospective review of obstetric records at a tertiary care facility. We assessed documentation of vital signs including fetal and maternal heart rate, and maternal blood pressure, temperature, oxygen saturation and urine output. The primary outcome was the quality of vital sign monitoring (high- versus low-quality based on frequency of monitoring). We compared quality of monitoring with timing of admission, presence of complication, and delivery mode using chi-squared tests. RESULTS: among 360 records of obstetric admissions (94% of a planned random sample), 96% documented a delivery. Of these, 8% of pregnant women and 11% of postpartum women had high-quality vital sign monitoring documented on initial evaluation at admission. For women delivering during the hospitalization, 0.8% of women delivering had high-quality monitoring in the first four hours postpartum, with higher rates of high-quality monitoring in women delivering vaginally compared to those delivered by cesarean (1.4% versus 0%, p<0.001). There were no differences in rates of quality monitoring by time of admission, or obstetric complication. CONCLUSION: very few obstetric hospitalizations had high-quality vital sign monitoring. Attention towards improving vital sign monitoring is a critical need.

Obesity in Pregnancy: ACOG Practice Bulletin, Number 230.

Obstetrician-gynecologists are the leading experts in the health care of women, and obesity is the most common medical condition in women of reproductive age. Obesity in women is such a common condition that the implications relative to pregnancy often are unrecognized, overlooked, or ignored because of the lack of specific evidence-based treatment options. The management of obesity requires long-term approaches ranging from population-based public health and economic initiatives to individual nutritional, behavioral, or surgical interventions. Therefore, an understanding of the management of obesity during pregnancy is essential, and management should begin before pregnancy and continue through the postpartum period. Although the care of the obese woman during pregnancy requires the involvement of the obstetrician or other obstetric care professional, additional health care professionals, such as nutritionists, can offer specific expertise related to management depending on the comfort level of the obstetric care professional. The purpose of this Practice Bulletin is to offer an integrated approach to the management of obesity in women of reproductive age who are planning a pregnancy.

Lack of experience is a main cause of maternal death in placenta accreta spectrum patients.

INTRODUCTION: Placenta accreta spectrum (PAS) is a serious condition with a mortality as high as 7%. However, the factors associated with this type of death have not been adequately described, with an almost complete lack of publications analyzing the determining factors of death in this disease. The aim of our work is to describe the causes of death related to PAS and to analyze the associated diagnosis and treatment problems. MATERIAL AND METHODS: This is an inter-continental, multicenter, descriptive, retrospective study in low- and middle-income countries. Maternal deaths related to PAS between January 2015 and December 2020 were included. Crucial points in the management of PAS, including prenatal diagnosis and details of the surgical treatment and postoperative management, were evaluated. RESULTS: Eighty-two maternal deaths in 16 low- and middle-income countries, on three continents, were included. Almost all maternal deaths (81 cases, 98.8%) were preventable, with inexperience among surgeons being identified as the most relevant problem in the process that led to death among 87% (67 women) of the cases who had contact with health services. The main cause of death associated with PAS was hemorrhage (69 cases, 84.1%), and failures in the process leading to the diagnosis were detected among 64.6% of cases. Although the majority of cases received medical attention and 50 (60.9%) were treated at referral centers for severe obstetric disease, problems were identified during treatment in all cases. CONCLUSIONS: Lack of experience and inadequate surgical technique are the most frequent problems associated with maternal deaths in PAS. Continuous training of interdisciplinary teams is critical to modify this tendency.

The development of the WHO Labour Care Guide: an international survey of maternity care providers.

BACKGROUND: The partograph is the most commonly used labour monitoring tool in the world. However, it has been used incorrectly or inconsistently in many settings. In 2018, a WHO expert group reviewed and revised the design of the partograph in light of emerging evidence, and they developed the first version of the Labour Care Guide (LCG). The objective of this study was to explore opinions of skilled health personnel on the first version of the WHO Labour Care Guide. METHODS: Skilled health personnel (including obstetricians, midwives and general practitioners) of any gender from Africa, Asia, Europe and Latin America were identified through a large global research network. Country coordinators from the network invited 5 to 10 mid-level and senior skilled health personnel who had worked in labour wards anytime in the last 5 years. A self-administered, anonymous, structured, online questionnaire including closed and open-ended questions was designed to assess the clarity, relevance, appropriateness of the frequency of recording, and the completeness of the sections and variables on the LCG. RESULTS: A total of 110 participants from 23 countries completed the survey between December 2018 and January 2019. Variables included in the LCG were generally considered clear, relevant and to have been recorded at the appropriate frequency. Most sections of the LCG were considered complete. Participants agreed or strongly agreed with the overall design, structure of the LCG, and the usefulness of reference thresholds to trigger further assessment and actions. They also agreed that LCG could potentially have a positive impact on clinical decision-making and respectful maternity care. Participants disagreed with the value of some variables, including coping, urine, and neonatal status. CONCLUSIONS: Future end-users of WHO Labour Care Guide considered the variables to be clear, relevant and appropriate, and, with minor improvements, to have the potential to positively impact clinical decision-making and respectful maternity care.