Time to redefine prolonged third stage of labor? A systematic review and meta-analysis of the length of the third stage of labor and adverse maternal outcome after vaginal birth.

OBJECTIVE: This study aimed (1) to assess the association between the length of the third stage of labor and adverse maternal outcome after vaginal birth and (2) to evaluate whether earlier manual placenta removal reduces the risk of adverse outcome. DATA SOURCES: PubMed, MEDLINE, Embase, ClinicalTrials.gov, the Cochrane Library, Journals@Ovid, and the World Health Organization International Clinical Trials Registry were searched from January 1, 2000, to June 13, 2023. STUDY ELIGIBILITY CRITERIA: All studies that assessed adverse maternal outcome, defined as any maternal complication after vaginal birth, concerning the length of the third stage of labor and the timing of manual placenta removal were included. METHODS: The included studies were evaluated using the Conducting Systematic Reviews and Meta-Analyses of Observational Studies of Etiology methodology. Pooled odds ratios with 95% confidence intervals were calculated. Heterogeneity (I2 test) was assessed, subgroup analyses were performed, and 95% prediction intervals were calculated. RESULTS: To meet the first objective, 18 cohort studies were included. The assessed cutoff values for the length of the third stage of labor were 15, 30, and 60 minutes. Women with a third stage of labor of ≥15 minutes had an increased risk of postpartum hemorrhage compared with those with a third stage of labor of <15 minutes (odds ratio, 5.55; 95% confidence interval, 1.74-17.72). For women without risk factors for postpartum hemorrhage, the odds ratio was 2.20 (95% confidence interval, 0.75-6.49). Among women with a third stage of labor of ≥60 minutes vs women with a third stage of labor of <60 minutes, the odds ratio was 3.72 (95% confidence interval, 2.36-5.89). The incidence of red blood cell transfusion was higher for a third stage of labor of ≥30 minutes than for a third stage of labor of <30 minutes (odds ratio, 3.23; 95% confidence interval, 2.26-4.61). Of note, 3 studies assessed the timing of placenta removal and the risk of adverse maternal outcome. However, the results could not be pooled because of the different outcome measures. Moreover, 1 randomized controlled trial (RCT) reported a significantly higher incidence of hemodynamic compromise in women with manual placenta removal at 15 minutes than in women with manual placenta removal at 10 minutes (30/156 [19.2%] vs 10/156 [6.4%], respectively), whereas 2 observational studies reported a lower risk of bleeding among women without manual placenta removal. CONCLUSION: Although the risk of adverse maternal outcome after vaginal birth increases when the third stage of labor exceeds 15 minutes, there is no convincing supporting evidence that reducing the length of the third stage of labor by earlier manual removal of the placenta can reduce the incidence of adverse maternal outcome.

The contribution of suicide to maternal mortality: A nationwide population-based cohort study.

OBJECTIVE: To identify the incidence and characteristics of maternal suicide. DESIGN: Nationwide population-based cohort study. SETTING: The Netherlands, 2006-2020. POPULATION: Women who died during pregnancy or within 1 year postpartum, and a reference population of women aged 25-45 years. METHODS: The Cause of Death Register and Medical Birth Register were linked to identify women who died within 1 year postpartum. Data were combined with deaths reported to the Audit Committee for Maternal Mortality and Morbidity (ACMMM), which performs confidential enquiries. Maternal suicides were compared with a previous period (1996-2005). Risk factors were obtained by combining vital statistics databases. MAIN OUTCOME MEASURES: Comparison of incidence and proportion of maternal suicides among all maternal deaths over time, sociodemographic and patient-related risk factors and underreporting of postpartum suicides. RESULTS: The maternal suicide rate remained stable with 68 deaths: 2.6 per 100 000 live births in 2006-2020 versus 2.5 per 100 000 in 1996-2005. The proportion of suicides among all maternal deaths increased from 18% to 28%. Most suicides occurred throughout the first year postpartum (64/68); 34 (53%) of the women who died by suicide postpartum were primiparous. Compared with mid-level, low educational level was a risk factor (odds ratio 4.2, 95% confidence interval 2.3-7.9). Of 20 women reported to the ACMMM, 11 (55%) had a psychiatric history and 13 (65%) were in psychiatric treatment at the time of death. Underreporting to ACMMM was 78%. CONCLUSIONS: Although the overall maternal mortality ratio declined, maternal suicides did not and are now the leading cause of maternal mortality if late deaths up to 1 year postpartum are included. Data collection and analysis of suicides must improve.

The influence of chorioamnionitis on respiratory drive and spontaneous breathing of premature infants at birth: a narrative review.

Most very premature infants breathe at birth but require respiratory support in order to stimulate and support their breathing. A significant proportion of premature infants are affected by chorioamnionitis, defined as an umbrella term for antenatal inflammation of the foetal membranes and umbilical vessels. Chorioamnionitis produces inflammatory mediators that potentially depress the respiratory drive generated in the brainstem. Such respiratory depression could maintain itself by delaying lung aeration, hampering respiratory support at birth and putting infants at risk of hypoxic injury. This inflammatory-mediated respiratory depression may contribute to an association between chorioamnionitis and increased requirement of neonatal resuscitation in premature infants at birth. This narrative review summarises mechanisms on how respiratory drive and spontaneous breathing could be influenced by chorioamnionitis and provides possible interventions to stimulate spontaneous breathing.  Conclusion: Chorioamnionitis could possibly depress respiratory drive and spontaneous breathing in premature infants at birth. Interventions to stimulate spontaneous breathing could therefore be valuable. What is Known: • A large proportion of premature infants are affected by chorioamnionitis, antenatal inflammation of the foetal membranes and umbilical vessels. What is New: • Premature infants affected by chorioamnionitis might be exposed to higher concentrations of respiratory drive inhibitors which could depress breathing at birth. • Premature infants affected by chorioamnionitis seem to be associated with a higher and more extensive requirement of resuscitation at birth.

The effect of histological and subclinical chorioamnionitis and funisitis on breathing effort in premature infants at birth: a retrospective cohort study.

Antenatal inflammation in the form of chorioamnionitis (fetal membranes; HCA) and funisitis (umbilical vessels; FUN) is a major risk factor for preterm birth. Exposure to HCA + FUN affects infants by releasing mediators that may suppress respiratory drive. While the association between clinical chorioamnionitis (CCA) and (depressed) spontaneous breathing has been described, we have investigated the association between breathing and HCA + FUN. Infants born < 30 weeks' gestation with available placental pathology assessments were included. Infants were compared at multiple levels: infants with vs without HCA + FUN (comparison 1) and infants with subclinical HCA + FUN vs infants without any chorioamnionitis (comparison 2). The primary outcome was breathing effort, defined as minute volume (MV) of spontaneous breathing in the first 5 min after birth. We also assessed tidal volume (Vt), respiratory rate (RR), heart rate (HR), oxygen saturation (SpO2) and oxygen requirement (FiO2). Regression analyses were performed to control for confounding factors. One hundred eighty-six infants were included (n = 75 infants with HCA + FUN vs. n = 111 infants without HCA + FUN). Comparison 1: Infants with HCA + FUN had lower gestational ages 26+5 (25+0-28+1; median (IQR) and lower birthweights (mean ± SD; 943 ± 264) compared to infants without HCA + FUN (28+4 (27+0-29+1) weeks, p < 0.001 and 1023 ± 270 g, p = 0.049). Comparison 2: Subclinical HCA + FUN was diagnosed in 46/75 HCA + FUN infants. Infants with subclinical HCA + FUN had lower gestational ages (26+6 (25+1-28+3) vs. 28+4 (27+2-29+1) weeks, p < 0.001) without significant differences for birthweights (987 ± 248 vs. 1027 ± 267 g, p = 0.389) compared to infants without any chorioamnionitis (n = 102 infants). After adjustment, HCA + FUN was associated with lower MV (p = 0.025), but subclinical HCA + FUN was not (p = 0.226). HCA + FUN and subclinical HCA + FUN were associated with lower Vt (p = 0.003; p = 0.014), SpO2 at 5 min (p = 0.021; 0.036) and SpO2/FiO2 ratio (p = 0.028; p = 0.040). CONCLUSION: HCA + FUN and subclinical HCA + FUN are associated with reduced oxygenation and parameters that reflect breathing effort in premature infants at birth. WHAT IS KNOWN: • Acute antenatal inflammation, in the form of chorioamnionitis (fetal membranes) and funisitis (umbilical vessels), affects a large proportion of premature infants. • Clinical chorioamnionitis is associated with reduced breathing effort and oxygenation in premature infants at birth. WHAT IS NEW: • Histological and subclinical chorioamnionitis and funisitis are associated with reduced breathing effort parameters and oxygenation in premature infants at birth.

Temporalities of oxytocin for labour augmentation: a mixed-methods study of time factors shaping labour practices in a busy maternity unit in Tanzania.

BACKGROUND: High rates of labour augmentation with oxytocin have been found in some low- and lower-middle-income countries, causing potential perinatal harm. It is critical to understand the reasons for this overuse. Aim was to explore factors that shape practices around using oxytocin for labour augmentation in a high-volume labour ward in Dar es Salaam, Tanzania. METHODS: Mixed-methods data collection was conducted from March 2021 to February 2022, including structured observations of 234 births, 220 h of unstructured labour ward observations and 13 individual in-depth interviews with birth attendants. Thematic network analysis and descriptive statistics were used to analyse data. We used a time-lens to understand practices of oxytocin for labour augmentation in time-pressured labour wards. RESULTS: Birth attendants constantly had to prioritise certain care practices over others in response to time pressure. This led to overuse of oxytocin for augmentation to ensure faster labour progression and decongestion of the, often overburdened, ward. Simultaneously, birth attendants had little time to monitor foetal and maternal condition. Surprisingly, while oxytocin was used in 146 out of 234 (62.4%) structured labour observations, only 9/234 (4.2%) women had active labour lasting more than 12 h. Correspondingly, 21/48 (43.8%) women who were augmented with oxytocin in the first stage of labour had uncomplicated labour progression at the start of augmentation. While the partograph was often not used for decision-making, timing of starting oxytocin often correlated with natural cycles of ward-rounds and shift-turnovers instead of individual women's labour progression. This resulted in co-existence of 'too early' and 'too late' use of oxytocin. Liberal use of oxytocin for labour augmentation was facilitated by an underlying fear of prolonged labour and low alertness of oxytocin-related risks. CONCLUSIONS: Time scarcity in the labour ward often made birth attendants deviate from clinical guidelines for labour augmentation with oxytocin. Efforts to navigate time pressure resulted in too many women with uncomplicated labour progression receiving oxytocin with little monitoring of labour. Fear of prolonged labour and low alertness to oxytocin-mediated risks were crucial drivers. These findings call for research into safety and benefits of oxytocin in low-resource settings and interventions to address congestion in labour wards to prevent using oxytocin as a time-management tool.

Incidence and determinants of perinatal mortality in five urban hospitals in Dar es Salaam, Tanzania: a cohort study with an embedded case-control analysis.

INTRODUCTION: Tanzania has one of the highest burdens of perinatal mortality, with a higher risk among urban versus rural women. To understand the characteristics of perinatal mortality in urban health facilities, study objectives were: I. To assess the incidence of perinatal deaths in public health facilities in Dar es Salaam and classify these into a) pre-facility stillbirths (absence of fetal heart tones on admission to the study health facilities) and b) intra-facility perinatal deaths before discharge; and II. To identify determinants of perinatal deaths by comparing each of the two groups of perinatal deaths with healthy newborns. METHODS: This was a retrospective cohort study among women who gave birth in five urban, public health facilities in Dar es Salaam. I. Incidence of perinatal death in the year 2020 was calculated based on routinely collected health facility records and the Perinatal Problem Identification Database. II. An embedded case-control study was conducted within a sub-population of singletons with birthweight ≥ 2000 g (excluding newborns with congenital malformations); pre-facility stillbirths and intra-facility perinatal deaths were compared with 'healthy newborns' (Apgar score ≥ 8 at one and ≥ 9 at five minutes and discharged home alive). Descriptive and logistic regression analyses were performed to explore the determinants of deaths. RESULTS: A total of 37,787 births were recorded in 2020. The pre-discharge perinatal death rate was 38.3 per 1,000 total births: a stillbirth rate of 27.7 per 1,000 total births and an intra-facility neonatal death rate of 10.9 per 1,000 live births. Pre-facility stillbirths accounted for 88.4% of the stillbirths. The case-control study included 2,224 women (452 pre-facility stillbirths; 287 intra-facility perinatal deaths and 1,485 controls), 99% of whom attended antenatal clinic (75% with more than three visits). Pre-facility stillbirths were associated with low birth weight (cOR 4.40; (95% CI: 3.13-6.18) and with maternal hypertension (cOR 4.72; 95% CI: 3.30-6.76). Intra-facility perinatal deaths were associated with breech presentation (aOR 40.3; 95% CI: 8.75-185.61), complications in the second stage (aOR 20.04; 95% CI: 12.02-33.41), low birth weight (aOR 5.57; 95% CI: 2.62-11.84), cervical dilation crossing the partograph's action line (aOR 4.16; 95% CI:2.29-7.56), and hypertension during intrapartum care (aOR 2.9; 95% CI 1.03-8.14), among other factors.  CONCLUSION: The perinatal death rate in the five urban hospitals was linked to gaps in the quality of antenatal and intrapartum care, in the study health facilities and in lower-level referral clinics. Urgent action is required to implement context-specific interventions and conduct implementation research to strengthen the urban referral system across the entire continuum of care from pregnancy onset to postpartum. The role of hypertensive disorders in pregnancy as a crucial determinant of perinatal deaths emphasizes the complexities of maternal-perinatal health within urban settings.

Does higher performance in a national licensing examination predict better quality of care? A longitudinal observational study of Ethiopian anesthetists.

BACKGROUND: Ethiopia made a national licensing examination (NLE) for associate clinician anesthetists a requirement for entry into the practice workforce. However, there is limited empirical evidence on whether the NLE scores of associate clinicians predict the quality of health care they provide in low-income countries. This study aimed to assess the association between anesthetists' NLE scores and three selected quality of patient care indicators. METHODS: A multicenter longitudinal observational study was conducted between January 8 and February 7, 2023, to collect quality of care (QoC) data on surgical patients attended by anesthetists (n = 56) who had taken the Ethiopian anesthetist NLE since 2019. The three QoC indicators were standards for safe anesthesia practice, critical incidents, and patient satisfaction. The medical records of 991 patients were reviewed to determine the standards for safe anesthesia practice and critical incidents. A total of 400 patients responded to the patient satisfaction survey. Multivariable regressions were employed to determine whether the anesthetist NLE score predicted QoC indicators. RESULTS: The mean percentage of safe anesthesia practice standards met was 69.14%, and the mean satisfaction score was 85.22%. There were 1,120 critical incidents among 911 patients, with three out of five experiencing at least one. After controlling for patient, anesthetist, facility, and clinical care-related confounding variables, the NLE score predicted the occurrence of critical incidents. For every 1% point increase in the total NLE score, the odds of developing one or more critical incidents decreased by 18% (aOR = 0.82; 95% CI = 0.70 = 0.96; p = 0.016). No statistically significant associations existed between the other two QoC indicators and NLE scores. CONCLUSION: The NLE score had an inverse relationship with the occurrence of critical incidents, supporting the validity of the examination in assessing graduates' ability to provide safe and effective care. The lack of an association with the other two QoC indicators requires further investigation. Our findings may help improve education quality and the impact of NLEs in Ethiopia and beyond.

Incidence, Causes and Outcomes of Postpartum Hemorrhage in Eastern Ethiopia: A Multicenter Surveillance Study.

OBJECTIVES: Maternal mortality remains an unfinished global agenda and postpartum hemorrhage (PPH) remains one of the leading causes. The aims of this study were to describe the incidence, underlying causes, and case fatality rate of PPH in public hospitals in eastern Ethiopia. METHODS: This study was part of a larger Ethiopian Obstetric Surveillance System (EthOSS) project - a multicenter surveillance of women admitted to 13 public hospitals in eastern Ethiopia due to any of the five major obstetric conditions: obstetric hemorrhage, eclampsia, uterine rupture, sepsis, and severe anemia - conducted from April 1, 2021 to March 31, 2022. All registers in maternity units of those hospitals were reviewed to identify eligible women and collect data on sociodemographic and obstetric characteristics, management and maternal outcomes at discharge or death. Findings were reported using descriptive statistics. RESULTS: Among 38,782 births registered during the study period, 2043 women were admitted with at least one of the five major obstetric conditions. Of these 2043, 306 women (15%) had PPH corresponding with an incidence rate of 8 (95% CI: 7-9) per 1000 births. Uterine atony was the main underlying cause in 77%; 81% of women with PPH received at least one uterotonic drug, and 72% of women for whom blood was requested received at least one unit. Of the 70 hospital based maternal deaths, 19 (27%) died from PPH, making a case fatality rate of 6 per 100. CONCLUSIONS: Although the overall incidence of PPH appeared low, it was still the underlying cause of death in one out of four women who died. The contributing factors might be that one in five women with PPH did not receive any uterotonic drug and the low blood transfusion. Ongoing audit, followed by targeted action, is essential to improve care quality and reduce adverse maternal outcome. The relatively low incidence may reflect under-recording in paper-based records, implying that further research into methods to optimize the surveillance is needed.

Maternal and perinatal death surveillance and response: a systematic review of qualitative studies.

Objective: To understand the experiences and perceptions of people implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries, and the mechanisms by which this process can achieve its intended outcomes. Methods: In June 2022, we systematically searched seven databases for qualitative studies of stakeholders implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries. Two reviewers independently screened articles and assessed their quality. We used thematic synthesis to derive descriptive themes and a realist approach to understand the context-mechanism-outcome configurations. Findings: Fifty-nine studies met the inclusion criteria. Good outcomes (improved quality of care or reduced mortality) were underpinned by a functional action cycle. Mechanisms for effective death surveillance and response included learning, vigilance and implementation of recommendations which motivated further engagement. The key context to enable effective death surveillance and response was a blame-free learning environment with good leadership. Inadequate outcomes (lack of improvement in care and mortality and discontinuation of death surveillance and response) resulted from a vicious cycle of under-reporting, inaccurate data, and inadequate review and recommendations, which led to demotivation and disengagement. Some harmful outcomes were reported, such as inappropriate referrals and worsened staff shortages, which resulted from a fear of negative consequences, including blame, disciplinary action or litigation. Conclusion: Conditions needed for effective maternal and/or perinatal death surveillance and response include: separation of the process from litigation and disciplinary procedures; comprehensive guidelines and training; adequate resources to implement recommendations; and supportive supervision to enable safe learning.

"My baby is fine, no need for more clinic visits." Facilitators and barriers for utilisation of follow-up services for children born preterm in low-resource setting: Parents' perceptions.

OBJECTIVES: We sought to understand the facilitators and barriers impacting utilisation of follow-up services for children born preterm as perceived by parents in a low-resource setting. METHODS: We conducted a qualitative study at Mulago Hospital, Uganda, with parents of children born preterm and aged 22-38 months at the time of the study. We collected data using five in-depth interviews and four focus group discussions. Data were analysed using thematic analysis informed by the social-ecological model. RESULTS: Ten subthemes emerged that could be grouped into three main themes: (1) Individual: parents' knowledge, parenting skills, perception of follow-up and infant's condition; (2) Relationship: support for the mother and information sharing; (3) Institution: facility setup, cost of care, available personnel and distance from the facility. Parents of preterm infants perceived receiving timely information, better understanding of prematurity and its complications, support from spouses, availability of free services and encouragement from health workers as facilitators for utilisation of follow-up services. Limited male involvement, parents' negative perception of follow-up, stable condition of infant, health facility challenges especially congestion at the hospital, distance and care costs were key barriers. CONCLUSION: An interplay of facilitators and barriers at individual, interpersonal and health system levels encourage or deter parents from taking their preterm children for follow-up services. Improving utilisation of services will require educating parents on the importance of follow-up even when children are not sick, eliciting maternal support from spouses and peers and addressing health system gaps that make follow-up unattractive and costly.

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.

Vacuum extraction or caesarean section in the second stage of labour: A systematic review.

BACKGROUND: Prolonged second stage of labour is an important cause of maternal and perinatal morbidity and mortality. Vacuum extraction (VE) and second-stage caesarean section (SSCS) are the most commonly performed obstetric interventions, but the procedure chosen varies widely globally. OBJECTIVES: To compare maternal and perinatal morbidity, mortality and other adverse outcomes after VE versus SSCS. SEARCH STRATEGY: A systematic search was conducted in PubMed, Cochrane and EMBASE. Studies were critically appraised using the Newcastle-Ottawa scale. SELECTION CRITERIA: All artictles including women in second stage of labour, giving birth by vacuum extraction or cesarean section and registering at least one perinatal or maternal outcome were selected. DATA COLLECTION AND ANALYSIS: The chi-square test, Fisher exact's test and binary logistic regression were used and various adverse outcome scores were calculated to evaluate maternal and perinatal outcomes. MAIN RESULTS: Fifteen articles were included, providing the outcomes for a total of 20 051 births by SSCS and 32 823 births by VE. All five maternal deaths resulted from complications of anaesthesia during SSCS. In total, 133 perinatal deaths occurred in all studies combined: 92/20 051 (0.45%) in the SSCS group and 41/32 823 (0.12%) in the VE group. In studies with more than one perinatal death, both conducted in low-resource settings, more perinatal deaths occurred during the decision-to-birth interval in the SSCS group than in the VE group (5.5% vs 1.4%, OR 4.00, 95% CI 1.17-13.70; 11% vs 8.4%, OR 1.39, 95% CI 0.85-2.26). All other adverse maternal and perinatal outcomes showed no statistically significant differences. CONCLUSIONS: Vacuum extraction should be the recommended mode of birth, both in high-income countries and in low- and middle-income countries, to prevent unnecessary SSCS and to reduce perinatal and maternal deaths when safe anaesthesia and surgery is not immediately available.

Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines.

OBJECTIVE: To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH. DESIGN: Comparative study. SETTING: High-resource countries. POPULATION: Women with PPH. METHODS: Systematic comparison of guidance on PPH from eight high-income countries. MAIN OUTCOME MEASURES: Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour. CONCLUSIONS: Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines. RESULTS: Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.

Spontaneous haemoperitoneum in pregnancy: Nationwide surveillance and Delphi audit system.

OBJECTIVE: To evaluate the incidence, diagnostic management strategies and clinical outcomes of women with spontaneous haemoperitoneum in pregnancy (SHiP) and reassess the definition of SHiP. DESIGN: A population-based cohort study using the Netherlands Obstetric Surveillance System (NethOSS). SETTING: Nationwide, the Netherlands. POPULATION: All pregnant women between April 2016 and April 2018. METHODS: This is a case study of SHiP using the monthly registry reports of NethOSS. Complete anonymised case files were obtained. A newly introduced online Delphi audit system (DAS) was used to evaluate each case, to make recommendations on improving the management of SHiP and to propose a new definition of SHiP. MAIN OUTCOME MEASURES: Incidence and outcomes, lessons learned about clinical management and the critical appraisal of the current definition of SHiP. RESULTS: In total, 24 cases were reported. After a Delphi procedure, 14 cases were classified as SHiP. The nationwide incidence was 4.9 per 100 000 births. Endometriosis and conceiving after artificial reproductive techniques were identified as risk factors. No maternal and three perinatal deaths occurred. Based on the DAS, adequate imaging of free intra-abdominal fluid, and identifying and treating women with signs of hypovolemic shock could improve the early detection and management of SHiP. A revised definition of SHiP was proposed, excluding the need for surgical or radiological intervention. CONCLUSIONS: SHiP is a rare and easily misdiagnosed condition that is associated with high perinatal mortality. To improve care, better awareness among healthcare workers is needed. The DAS is a sufficient tool to audit maternal morbidity and mortality.

Variations over time in mode of birth and perinatal outcomes in women with one previous cesarean in the Netherlands: A 20-year population-based study.

BACKGROUND: Globally, cesarean birth rates are rising, and while it can be a lifesaving procedure, cesarean birth is also associated with increased maternal and perinatal risks. This study aims to describe changes over time about the mode of birth and perinatal outcomes in second-pregnancy women with one previous cesarean birth in the Netherlands over the past 20 years. METHODS: We conducted a nationwide, population-based study using the Dutch perinatal registry. The mode of birth (intended vaginal birth after cesarean (VBAC) compared with planned cesarean birth) was assessed in all women with one previous cesarean birth and no prior vaginal birth who gave birth to a term singleton in cephalic presentation between 2000 and 2019 in the Netherlands (n = 143,146). The reported outcomes include the trend of intended VBAC, VBAC success rate, and adverse perinatal outcomes (perinatal mortality up to 7 days, low Apgar score at 5 min, asphyxia, and neonatal intensive care unit admission ≥24 h). RESULTS: Intended VBAC decreased by 21.5% in women with one previous cesarean birth and no prior vaginal birth, from 77.2% in 2000 to 55.7% in 2019, with a marked deceleration from 2009 onwards. The VBAC success rate dropped gradually, from 71.0% to 65.3%, across the same time period. Overall, the cesarean birth rate (planned and unplanned) increased from 45.2% to 63.6%. Adverse perinatal outcomes were higher in women intending VBAC compared with those planning a cesarean birth. Perinatal mortality initially decreased but remained stable from 2009 onwards, with only minimal differences between both modes of birth. CONCLUSIONS: In the Netherlands, the proportion of women intending VBAC after one previous cesarean birth and no prior vaginal birth has decreased markedly. Particularly from 2009 onwards, this decrease was not accompanied by a synchronous reduction in perinatal mortality.

(Un)warranted variation in local hospital protocols for neonatal referral to the pediatrician: An explorative study in the Netherlands.

BACKGROUND: Studies indicate unwarranted variation in a wide range of neonatal care practices, contributing to preventable morbidity and mortality. Unwarranted variation is the result of complex interactions and multiple determinants. One of the determinants contributing to unwarranted variation in care may be variation in local hospital protocols. The purpose of this study was to examine variation in the content of obstetric and neonatal protocols for six common indications for neonatal referral to the pediatrician: large for gestational age/macrosomia, small for gestational age/fetal growth restriction, meconium-stained amniotic fluid, vacuum extraction, forceps extraction, and cesarean birth. METHODS: We conducted a nationwide cross-sectional study examining protocols for neonatal referral to the pediatrician in the obstetric and neonatal departments of all Dutch hospitals. Variation in protocols was analyzed between regions, between neonatal and obstetrics departments located in the same hospital, and within neonatal and obstetrics departments. RESULTS: There was considerable variation in protocols between regions, between neonatal and obstetrics departments, and within neonatal and obstetrics departments. The results of this study showed considerable variation in recommendations for type of referral, admission, screening/diagnostic tests, treatment, and discharge. Furthermore, results generally showed lower referral thresholds in neonatal departments compared with obstetric departments, and higher referral thresholds in the eastern region of the Netherlands. We also found variation in local hospital protocols, which could not be explained by population characteristics but which may be explained by varying recommendations in existing national and international guidelines and/or lack of adherence to these guidelines. CONCLUSIONS: To reduce unwarranted variation in local protocols, evidence-based, multidisciplinary guidelines should be developed in the Netherlands. Further research addressing knowledge gaps is needed to inform these guidelines. Attention should be paid to the implementation of evidence, and only where evidence is lacking or inconclusive should agreements be based on multidisciplinary consensus. Where protocols deviate from evidence-based guidelines because of specific local circumstances, clearer, more transparent justifications should be made. Uniformity in guidance will offer clear standards for care evaluation and provide opportunities to reduce inappropriate care.

Confidential Enquiry into Maternal Deaths in Namibia, 2018-2019: A Local Approach to Strengthen the Review Process and a Description of Review Findings and Recommendations.

OBJECTIVES: First objective was to strengthen the national maternal death review, by addressing local challenges with each step of the review cycle. Second objective was to describe review findings and compare these with available findings of previous reviews. METHODS: Confidential Enquiry into Maternal Deaths methodology was used to review maternal deaths. To improve reporting, the national committee focussed on addressing fear of blame among healthcare providers. Second focus was on dissemination of findings and acting on recommendations forthcoming the review. Reviewed were reported maternal deaths, that occurred between 1 April 2018 and 31 March 2019. RESULTS: Seventy maternal deaths were reported; for 69 (98.6%) medical records were available, compared to 80/119 (67.2%) in 2012-2015. Reported maternal mortality ratio increased with 48% (92/100,000 live births compared to 62/100,000 in 2012-2015). Obstetric haemorrhage was leading cause of death in the past three reviews. The "no name, no blame" policy, aiming to identify health system failures, rather than mistakes of individuals, was repeatedly explained to healthcare providers during facility visits. Recommendations based on findings of the review, such as retaining experienced staff, continuous in-service training and guidance, were shared with decision makers at regional and national levels. Healthcare providers received training based on review findings, which resulted in improved management of similar cases. CONCLUSIONS FOR PRACTICE: Enhanced implementation of Confidential Enquiry into Maternal Deaths was possible after addressing local challenges. Focussing on obtaining trust of healthcare providers and feeding back findings, resulted in better reporting and prevention of potential maternal deaths.

"So let me give you money, you give me what I want": decision-making priorities around contraceptive method and source choice among young women in Kenya.

BACKGROUND: Many factors influence young women's choice of contraceptive methods and where to source them, yet less is known about whether one of these choices (method or source) is prioritized and the relationship between these choices. This study qualitatively explored decision-making around contraceptive method and source choice among young women in Kenya. METHODS: In August-September 2019, 30 in-depth interviews were conducted with women ages 18-24 who had used two or more contraceptive methods and resided in three counties: Nairobi, Mombasa or Migori. Participants were recruited from public and private health facilities and pharmacies. Interview guides captured information about decision-making processes for each contraceptive method the respondent had ever used. Responses were audio-recorded, transcribed, translated into English, coded, and analyzed thematically. RESULTS: The majority of respondents knew which method they wanted to use prior to seeking it from a source. This was true for all types of methods that women ever used. Of the small number of respondents who selected their source first, most were in the post-partum period or experiencing side effects and sought counseling at a source before choosing a method. CONCLUSIONS: This study highlights the importance of providing young women with high quality counseling that provides full information about contraceptive options and addresses that young women's needs vary along the reproductive health continuum of care. This will ensure that young women have information to inform future contraceptive decision-making prior to seeking care.

Impact of anesthetist licensing examination on quality of education in Ethiopia: a qualitative study of faculty and student perceptions.

BACKGROUND: Ethiopia drastically increased the anesthesia workforce density by training 'associate clinician anesthetists' as a task-shifting and sharing strategy. However, there were growing concerns about educational quality and patient safety. Accordingly, the Ministry of Health introduced the anesthetist national licensing examination (NLE) to assure the quality of education. However, empirical evidence is scarce to support or refute the overall impact of NLEs, which are relatively costly for low- and middle-income settings. Therefore, this study aimed to explore the impact of introducing NLE on anesthetists' education in Ethiopia. METHODS: We conducted a qualitative study using a constructivist grounded theory approach. Data were prospectively collected from ten anesthetist teaching institutions. Fifteen in-depth interviews were conducted with instructors and academic leaders, and six focus groups were held with students and recently tested anesthetists. Additional data were gathered by analyzing relevant documents, including versions of curricula, academic committee minutes, program quality review reports, and faculty appraisal reports. Interviews and group discussions were audiotaped, transcribed verbatim and analyzed using Atlas.ti 9 software. RESULTS: Both faculty and students demonstrated positive attitudes toward the NLE. Student motivation, faculty performance, and curriculum strengthening were the three primary changes that emerged, resulting in three subsequent spin-offs on assessment, learning, and quality management practices. Academic leaders' dedication to evaluating examination data and turning these into action led to changes that improved education quality. Increased accountability, engagement, and collaboration were the predominant factors facilitating change. CONCLUSION: Our study indicates that the Ethiopian NLE has prompted anesthesia teaching institutions to improve their teaching, learning, and assessment practices. However, more work is required to improve exam acceptability among stakeholders and drive broader changes.

Experiences of a dedicated Heart and Maternal Health Service providing multidisciplinary care to pregnant women with cardiac disease in a tertiary centre in Namibia.

OBJECTIVES: First, to describe the implementation process, benefits and challenges of a multidisciplinary service for pregnant women with cardiac disease in Namibia. Second, to assess pregnancy outcomes in this population. METHODS: In a tertiary hospital in Namibia, a multidisciplinary service was implemented by staff of obstetric and cardiology departments and included preconception counselling, provision of antenatal care and reliable contraception. Management guidelines developed for high-income settings were used, since no locally adapted guidelines were available. A cohort study was performed to assess cardiac, obstetric and fetal outcomes. Included were pregnant women with cardiac disease, referred to this service between 1 August 2016 and 31 July 2018. RESULTS: Important benefits of this service were the integrated approach, improved access to reliable contraception and insight into drivers of poor outcome. Several challenges with use of available guidelines were encountered, as contextual factors specific to lower-income settings were not taken into consideration, such as higher rates of infection or barriers to access care. The cohort consisted of 65 women. Cardiac disease was diagnosed for the first time in 16 (24.6%) women, of whom 11 had pre-existing cardiac disease. These women presented more often with heart failure than women with known heart disease (75.0% vs. 6.1%, RR 12.5, 95% CI 3.9-38.0). Five women died. Cardiac events occurred in twenty-two women of whom eight developed thromboembolic events and two endocarditis. The majority had no indication for prophylaxis, based on available guidelines. Fetal events occurred in 36 pregnancies. After pregnancy more than half of women (35/65, 53.8%) were using long-acting reversible contraception. CONCLUSIONS: Despite several barriers, it was possible to implement a multidisciplinary service in a high-burden setting. Cardiac and fetal event rates in this cohort were high. To improve outcomes the focus should be on availability of context-specific guidelines and better detection of cardiac disease.