Alternative versus standard packages of antenatal care for low-risk pregnancy

A double-edged sword-telemedicine for maternal care during COVID-19: findings from a global mixed-methods study of healthcare providers

INTRODUCTION

The COVID-19 pandemic has led to a rapid implementation of telemedicine for the provision of maternal and newborn healthcare. The objective of this study was to document the experiences with providing telemedicine for maternal and newborn healthcare during the pandemic among healthcare professionals globally.

METHODS

The second round of a global online survey of maternal and newborn health professionals was conducted, disseminated in 11 languages. Data were collected between 5 July and 10 September 2020. The questionnaire included questions regarding background, preparedness and response to COVID-19, and experiences with providing telemedicine. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregated by country income level.

RESULTS

Responses from 1060 maternal and newborn health professionals were analysed. Telemedicine was used by 58% of health professionals and two-fifths of them reported not receiving guidelines on the provision of telemedicine. Key telemedicine practices included online birth preparedness classes, antenatal and postnatal care by video/phone, a COVID-19 helpline and online psychosocial counselling. Challenges reported lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack of non-verbal feedback and bonding, and distrust from patients. Telemedicine was considered as an important alternative to in-person consultations. However, health providers emphasised the lower quality of care and risk of increasing the already existing inequalities in access to healthcare.

CONCLUSIONS

Telemedicine has been applied globally to address disruptions of care provision during the COVID-19 pandemic. However, some crucial aspects of maternal and newborn healthcare seem difficult to deliver by telemedicine. More research regarding the effectiveness, efficacy and quality of telemedicine for maternal healthcare in different contexts is needed before considering long-term adaptations in provision of care away from face-to-face interactions. Clear guidelines for care provision and approaches to minimising socioeconomic and technological inequalities in access to care are urgently needed.

Knowledge, attitudes, practices, and influencing factors of anxiety among pregnant women in Wuhan during the outbreak of COVID-19: a cross-sectional study

Background

Prenatal anxiety has been a significant public health issue globally, leading to adverse health outcomes for mothers and children. The study aimed to evaluate the sociodemographic characteristics, knowledge, attitudes, and practices (KAP), and anxiety level of pregnant women during the coronavirus disease 2019 (COVID-19) epidemic in Wuhan and investigate the influencing factors for prenatal anxiety in this specific context.

Methods

Pregnant subjects’ KAP towards COVID-19 and their sociodemographics and pregnancy information were collected using questionnaires. The Zung Self-Rating Anxiety Scale (SAS) was used to assess anxiety status. Factors associated with the level of prenatal anxiety were analyzed by Pearson’s chi-square test and multivariable logistic regression analyses.

Results

The prenatal anxiety prevalence in this population was 20.8%. The mean score of knowledge was 13.2 ± 1.1 on a 0 ~ 14 scale. The attitudes and practices data showed that 580/ 817 (71.0%) were very concerned about the news of COVID-19, 455/817 (55.7%) considered the official media to be the most reliable information source for COVID-19, and 681/817 (83.4%) were anxious about the possibility of being infected by COVID-19. However, only 83/817 (10.2%) worried about contracting COVID-19 infection through the ultrasound transducer during a routing morphology scan. About two-thirds 528/817 (64.6%) delayed or canceled the antenatal visits. Approximately half of them 410/817 (50.2%) used two kinds of personal protection equipments (PPEs) during hospital visits. Logistic regression analysis revealed that the influential factors for prenatal anxiety included previous children in the family, knowledge score, media trust, worry of contracting the COVID-19 infection and worry about getting infected with COVID-19 from the ultrasound probe antenatal care (ANC) schedule.

Conclusion

Prenatal anxiety was prevalent among pregnant women in Wuhan during the outbreak of COVID-19. The current findings identified factors associated with the level of prenatal anxiety that could be targeted for psychological care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03561-7.

The effect of antenatal care on perinatal outcomes in Ethiopia: A systematic review and meta-analysis

BACKGROUND

The estimated annual global perinatal and neonatal death is four million. Stillbirths are almost equivalent to neonatal mortality, yet they have not received the same attention. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but its effectiveness as a means of reducing perinatal mortality has not been evaluated in Ethiopia. Therefore, we will identify the pooled effect of antenatal care on perinatal outcomes in Ethiopia.

METHODS

Medline, Embase, Cinahl, African journal online and Google Scholar was searched for articles published in English language between January 1990 and May 2020. Two independent assessors selected studies and extracted data from eligible articles. The Risk of Bias Assessment tool for Non-Randomized Studies was used to assess the quality of each included study. Data analysis was performed using RevMan 5.3. Heterogeneity and publication bias were assessed using I2 test statistical significance and Egger's test for small-study effects respectively. The random effect model was employed, and forest plot was used to present the risk ratio (RR) with 95% confidence interval (CI).

RESULTS

Thirteen out of seventeen included studies revealed antenatal care utilization had a significant association with perinatal outcomes. The pooled risk ratio by the random-effects model for perinatal death was 0.42 (95% CI: 0.34, 0.52); stillbirth 0.34 (95% CI: 0.25, 0.46); early neonatal death 0.85 (95% CI: 0.21. 3.49).

CONCLUSION

Women who attended at least one antenatal care visit were more likely to give birth to an alive neonate that survives compared to their counterpart. Therefore, the Ethiopian Ministry of health and other stakeholders should design tailored interventions to increase antenatal care utilization since it has been shown to reduce perinatal mortality.

Effects of Hurricane Michael on Access to Care for Pregnant Women and Associated Pregnancy Outcomes

Background: Disasters are associated with worse perinatal outcomes, perhaps due to inadequate prenatal care (PNC). Methods: Using 2017-2019 Florida vital statistics, we compared PNC use before and after Hurricane Michael. We categorized counties as most affected (Area A) or less affected (Area B and C). We examined whether Michael's effects on perinatal outcomes varied by maternity care availability and used the Baron and Kenny method to assess whether delayed PNC initiation mediated perinatal outcomes. Log-binomial regression and semi-parametric linear regression were used, controlling for maternal and ZIP code tabulation area characteristics. Results: Compared to the one-year period pre-Michael, the week of the first PNC was later in all areas in the one-year period post-Michael, with the largest change in Area A (adjusted difference 0.112, 95% CI: 0.055-0.169), where women were less likely to receive PNC overall (aRR = 0.994, 95% CI = 0.990-0.998) and more likely to have inadequate PNC (aRR = 1.193, 95% CI = 1.127-1.264). Michael's effects on perinatal outcomes did not vary significantly by maternity care availability within Area A. Delayed PNC initiation appeared to mediate an increased risk in small for gestational age (SGA) births after Michael. Conclusion: Women in Area A initiated PNC later and had a higher likelihood of inadequate PNC. Delayed PNC initiation may partially explain increased risk of SGA.

Association between Adherence with Recommended Antenatal Care in Low-Risk, Uncomplicated Pregnancy, and Maternal and Neonatal Adverse Outcomes: Evidence from Italy

Antenatal care (ANC) aims of monitoring wellbeing of mother and foetus during pregnancy. We validate a set of indicators aimed of measuring the quality of ANC of women on low-risk, uncomplicated pregnancy through their relationship with maternal and neonatal outcomes. We conducted a population-based cohort study including 122,563 deliveries that occurred between 2015 and 2017 in the Lombardy Region, Italy. Promptness and appropriateness of number and timing of gynaecological visits, ultrasounds and laboratory tests were evaluated. We assessed several maternal and neonatal outcomes. Log-binomial regression models were used to estimate prevalence ratio (PR), and corresponding 95% confidence interval (95% CI), for the exposure→outcome association. Compared with women who adhered with recommendations, those who were no adherent had a significant higher prevalence of maternal intensive care units admission (PR: 3.1, 95%CI: 1.2-7.9; and 2.7, 1.1-7.0 respectively for promptness of gynaecological visits, and appropriateness of ultrasound examinations), low Apgar score (1.6, 1.1-1.2; 1.9, 1.3-2.7; and 2.1, 1.5-2.8 respectively for appropriateness and promptness of gynaecological visits, and appropriateness of ultrasound examinations), and low birth weight (1.8, 1.5-2.3 for appropriateness of laboratory test examinations). Benefits for mothers and newborn are expected from improving adherence to guidelines-driven recommendations regarding antenatal care even for low-risk, uncomplicated pregnancies.

Antenatal interventions for preventing stillbirth, fetal loss and perinatal death: an overview of Cochrane systematic reviews

BACKGROUND

Stillbirth is generally defined as a death prior to birth at or after 22 weeks' gestation. It remains a major public health concern globally. Antenatal interventions may reduce stillbirths and improve maternal and neonatal outcomes in settings with high rates of stillbirth. There are several key antenatal strategies that aim to prevent stillbirth including nutrition, and prevention and management of infections.

OBJECTIVES

To summarise the evidence from Cochrane systematic reviews on the effects of antenatal interventions for preventing stillbirth for low risk or unselected populations of women.

METHODS

We collaborated with Cochrane Pregnancy and Childbirth's Information Specialist to identify all their published reviews that specified or reported stillbirth; and we searched the Cochrane Database of Systematic Reviews (search date: 29 Feburary 2020) to identify reviews published within other Cochrane groups. The primary outcome measure was stillbirth but in the absence of stillbirth data, we used perinatal mortality (both stillbirth and death in the first week of life), fetal loss or fetal death as outcomes. Two review authors independently evaluated reviews for inclusion, extracted data and assessed quality of evidence using AMSTAR (A Measurement Tool to Assess Reviews) and GRADE tools. We assigned interventions to categories with graphic icons to classify the effectiveness of interventions as: clear evidence of benefit or harm; clear evidence of no effect or equivalence; possible benefit or harm; or unknown benefit or harm or no effect or equivalence.

MAIN RESULTS

We identified 43 Cochrane Reviews that included interventions in pregnant women with the potential for preventing stillbirth; all of the included reviews reported our primary outcome 'stillbirth' or in the absence of stillbirth, 'perinatal death' or 'fetal loss/fetal death'. AMSTAR quality was high in 40 reviews with scores ranging from 8 to 11 and moderate in three reviews with a score of 7. Nutrition interventions Clear evidence of benefit: balanced energy/protein supplementation versus no supplementation suggests a probable reduction in stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94, 5 randomised controlled trials (RCTs), 3408 women; moderate-certainty evidence). Clear evidence of no effect or equivalence for stillbirth or perinatal death: vitamin A alone versus placebo or no treatment; and multiple micronutrients with iron and folic acid versus iron with or without folic acid. Unknown benefit or harm or no effect or equivalence: for all other nutrition interventions examined the effects were uncertain. Prevention and management of infections Possible benefit for fetal loss or death: insecticide-treated anti-malarial nets versus no nets (RR 0.67, 95% CI 0.47 to 0.97, 4 RCTs; low-certainty). Unknown evidence of no effect or equivalence: drugs for preventing malaria (stillbirth RR 1.02, 95% CI 0.76 to 1.36, 5 RCTs, 7130 women, moderate certainty in women of all parity; perinatal death RR 1.24, 95% CI 0.94 to 1.63, 4 RCTs, 5216 women, moderate-certainty in women of all parity). Prevention, detection and management of other morbidities Clear evidence of benefit: the following interventions suggest a reduction: midwife-led models of care in settings where the midwife is the primary healthcare provider particularly for low-risk pregnant women (overall fetal loss/neonatal death reduction RR 0.84, 95% CI 0.71 to 0.99, 13 RCTs, 17,561 women; high-certainty), training versus not training traditional birth attendants in rural populations of low- and middle-income countries (stillbirth reduction odds ratio (OR) 0.69, 95% CI 0.57 to 0.83, 1 RCT, 18,699 women, moderate-certainty; perinatal death reduction OR 0.70, 95% CI 0.59 to 0.83, 1 RCT, 18,699 women, moderate-certainty). Clear evidence of harm: a reduced number of antenatal care visits probably results in an increase in perinatal death (RR 1.14 95% CI 1.00 to 1.31, 5 RCTs, 56,431 women; moderate-certainty evidence). Clear evidence of no effect or equivalence: there was evidence of no effect in the risk of stillbirth/fetal loss or perinatal death for the following interventions and comparisons: psychosocial interventions; and providing case notes to women. Possible benefit: community-based intervention packages (including community support groups/women's groups, community mobilisation and home visitation, or training traditional birth attendants who made home visits) may result in a reduction of stillbirth (RR 0.81, 95% CI 0.73 to 0.91, 15 RCTs, 201,181 women; low-certainty) and perinatal death (RR 0.78, 95% CI 0.70 to 0.86, 17 RCTs, 282,327 women; low-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined. Screening and management of fetal growth and well-being Clear evidence of benefit: computerised antenatal cardiotocography for assessing infant's well-being in utero compared with traditional antenatal cardiotocography (perinatal mortality reduction RR 0.20, 95% CI 0.04 to 0.88, 2 RCTs, 469 women; moderate-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined.

AUTHORS' CONCLUSIONS

While most interventions were unable to demonstrate a clear effect in reducing stillbirth or perinatal death, several interventions suggested a clear benefit, such as balanced energy/protein supplements, midwife-led models of care, training versus not training traditional birth attendants, and antenatal cardiotocography. Possible benefits were also observed for insecticide-treated anti-malarial nets and community-based intervention packages, whereas a reduced number of antenatal care visits were shown to be harmful. However, there was variation in the effectiveness of interventions across different settings, indicating the need to carefully understand the context in which these interventions were tested. Further high-quality RCTs are needed to evaluate the effects of antenatal preventive interventions and which approaches are most effective to reduce the risk of stillbirth. Stillbirth (or fetal death), perinatal and neonatal death need to be reported separately in future RCTs of antenatal interventions to allow assessment of different interventions on these rare but important outcomes and they need to clearly define the target populations of women where the intervention is most likely to be of benefit. As the high burden of stillbirths occurs in low- and middle-income countries, further high-quality trials need to be conducted in these settings as a priority.

Individual and community socioeconomic factors related to the quality of antenatal care: a multilevel analysis of West and Central Africa

Antenatal care (ANC) can improve maternal health. We examined associations of individual and community socioeconomic status (SES) with the quality of ANC in West and Central Africa. Data were from the 2009-2011 UNICEF Multiple Indicator Cluster Surveys for women in seven countries (n = 24,718). Individual SES variables included women's education and wealth; community SES was defined as low or high poverty index. ANC quality was defined as receiving six services: blood pressure monitoring, blood tests, urine tests, malaria prophylaxis, tetanus vaccine, and HIV screening, and coded low or high. We used multilevel logistic regression to estimate fixed and random effects of individual and community SES on ANC quality. Less than one-fourth of women received high-quality ANC. Only small percentages of women had malaria prophylaxis and were counseled and tested for HIV. In adjusted country-stratified results, living in a poor community was associated with reduced odds of receiving high-quality ANC in six countries (Central African Republic: odds ratio, OR = 0.76; 95% confidence interval, CI:0.58-0.98; Chad: OR = 0.48; CI:0.32-0.74; Ghana: OR = 0.86; CI:0.61-0.97; Nigeria: OR = 0.74; CI:0.61-0.92; Sierra Leone: OR = 0.71; CI:0.57-0.91; and Togo: OR = 0.80; CI:0.47-0.91). The health system may be missing important opportunities to provide high-quality ANC and, thereby, improve pregnancy outcomes in these settings.

Strengths of community and health facilities based interventions in improving women and adolescents’ care seeking behaviors as approaches for reducing maternal mortality and improving birth outcome among low income communities of Egypt

Background

Provision of emergency obstetric care is considered the key for maternal mortality reduction worldwide. This study evaluated the impact of community- and facility-based educational programs on provision of emergency obstetric care in Egypt. The study focused on evaluating utilization of the available health services and care seeking behaviors of mothers in the childbearing period.

Methods

We implemented a package of community- and facility-focused educational interventions in two of Egypt’s lowest income governorates. At facility level, health professionals at rural health units from 21 villages over 5 years were trained. Mass media gathering, individual teaching at health facilities, printed materials and home-based care sessions were provided. Collectively, these interventions were designed to focusing on recognition of the early warning signs during pregnancy, delivery and postpartum period for timely referral to hospitals for 20,494 women and adolescents mothers.

Results

The impact of the interventions was highly reflected on the percent of mothers received care during their pregnancy period. Proper antenatal care at governmental or private health facilities was raised dramatically from 0.6 to 59.3% and those who utilized at least one family planning method from 61.4 to 74.4%. Accordingly, the rate of complications significantly reduced during pregnancy (38.1 to 15.1%), during delivery (24.1 to 13.1%) and during postpartum (81.7 to 7.0%). As an impact to the improvement, there was a marked reduction in adolescent pregnancy by 55% and better birth outcome with a reduction in the percent of stillbirth by 11.5%.

Conclusion

It is important to provide a comprehensive package that works at both improving qualities of care as well as empowering women by knowledge to first aid measures at the community level. The cost-effective way to empower mothers to provide first aid measures as emergency obstetric care is to adopt the outreach approach which could be more influential than mass media campaigns for the at-risk and vulnerable and low-income communities.

Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries

Background

Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming.

Objectives

The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs).

Methods

Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017).

Results

We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups.

Conclusion

Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.

Characteristics of online medical care consultation for pregnant women during the COVID-19 outbreak: cross-sectional study

OBJECTIVES

This study described the needs of pregnant women and the contents of online obstetric consultation in representative areas with various severity of the epidemic in China.

DESIGN

This was a cross- sectional study.

SETTING

Yue Yi Tong (YYT), a free online communication platform that allows pregnant women to consult professional obstetricians.

PARTICIPANTS

All the pregnant women who used the YYT platform.

INTERVENTION

From 10 to 23 February, we collected data on online obstetric consultations and participants' satisfaction through the YYT platform in the mild, moderate and severe epidemic areas which were defined according to the local confirmed cases. The primary outcomes were the reasons for online consultations by the severity of the epidemic. All the comparisons were performed using χ2 test. Statistical analysis was performed using SPSS V.24.

RESULTS

A total of 2599 pregnant women participated in this study, of whom 448 (17.24%), 1332 (51.25%) and 819 (31.51%) were from the mild, moderate and severe epidemic areas, respectively. The distribution of the amount of online consultations was significantly different not only in different areas (p<0.001) but also in different trimesters (p<0.001). A total of 957 participants completed the satisfaction part of the survey. In this study, 77.95% of the participants used e-health for the first time, and 94.63% of the participants were completely or mostly satisfied with the online consultations.

CONCLUSIONS

The distribution of the amount of online consultations was significantly different not only in different areas but also in different trimesters. In any trimester, the amount of consultations on the second category (obstetric care-seeking behaviour) was the highest in the severe epidemic areas. The needs for online consultations were substantial. In order to prevent irreversible obstetric adverse events, an appropriate antenatal care contingency plan with e-health services is highly recommended during the Public Health Emergency of International Concern.

[Preventive activities in women's care]

A review is presented of the scientific evidence on preventive activities in women's care in relation to pregnancy follow-up, preventive activities in the planning and follow-up of contraceptive methods, preventive activities in menopause, and the prevention of osteoporotic fractures.

Risk of complicated birth at term in nulliparous and multiparous women using routinely collected maternity data in England: cohort study

OBJECTIVES

To determine the rate of complicated birth at term in women classified at low risk according to the National Institute for Health and Care Excellence guideline for intrapartum care (no pre-existing medical conditions, important obstetric history, or complications during pregnancy) and to assess if the risk classification can be improved by considering parity and the number of risk factors.

DESIGN

Cohort study using linked electronic maternity records.

PARTICIPANTS

276 766 women with a singleton birth at term after a trial of labour in 87 NHS hospital trusts in England between April 2015 and March 2016.

MAIN OUTCOME MEASURE

A composite outcome of complicated birth, defined as a birth with use of an instrument, caesarean delivery, anal sphincter injury, postpartum haemorrhage, or Apgar score of 7 or less at five minutes.

RESULTS

Multiparous women without a history of caesarean section had the lowest rates of complicated birth, varying from 8.8% (4879 of 55 426 women, 95% confidence interval 8.6% to 9.0%) in those without specific risk factors to 21.8% (613 of 2811 women, 20.2% to 23.4%) in those with three or more. The rate of complicated birth was higher in nulliparous women, with corresponding rates varying from 43.4% (25  805 of 59 413 women, 43.0% to 43.8%) to 64.3% (364 of 566 women, 60.3% to 68.3%); and highest in multiparous women with previous caesarean section, with corresponding rates varying from 42.9% (3426 of 7993 women, 41.8% to 44.0%) to 66.3% (554 of 836 women, 63.0% to 69.5%).

CONCLUSIONS

Nulliparous women without risk factors have substantially higher rates of complicated birth than multiparous women without a previous caesarean section even if the latter have multiple risk factors. Grouping women first according to parity and previous mode of birth, and then within these groups according to presence of specific risk factors would provide greater and more informed choice to women, better targeting of interventions, and fewer transfers during labour than according to the presence of risk factors alone.

Prenatal care redesign: creating flexible maternity care models through virtual care

Each year, nearly 4 million pregnant patients in the United States receive prenatal care—a crucial preventive service that improves pregnancy outcomes for mothers and their children. National guidelines currently recommend 12–14 in-person prenatal visits, a schedule that has remained unchanged since 1930. When scrutinizing the standard prenatal visit schedule, it becomes clear that prenatal care is overdue for a redesign. We have strong evidence of the benefits of prenatal services, such as screening for gestational diabetes and maternal vaccination. However, how to deliver these services is not clear. Studies of prenatal services consistently demonstrate that such care can be delivered in fewer than 14 visits and that patients do not need to visit clinics in person to receive all maternity services. Telemedicine has emerged as a promising care delivery option for patients seeking greater flexibility, and early trials leveraging virtual care and remote monitoring have shown positive maternal and fetal outcomes with high patient satisfaction.

Our institution has worked for the past year on a new prenatal care pathway. Our initial work assessed the literature, elicited patient perspectives, and captured the insights of experts in patient-centered care delivery. There are 2 key principles that guide prenatal care redesign: (1) design care delivery around essential services, using in-person care for services that cannot be delivered remotely and offering video visits for other essential services, and (2) creation of flexible services for anticipatory guidance and psychosocial support that allow patients to tailor support to meet their needs through opt-in programs. The rise of coronavirus disease 2019 prompted us to extend this early work and rapidly implement a redesigned prenatal care pathway. In this study, we outline our experience in transitioning to a new prenatal care model with 4 in-person visits, 1 ultrasound visit, and 4 virtual visits (the 4-1-4 prenatal plan). We then explore how insights from this implementation can inform patient-centered prenatal care redesign during and beyond the coronavirus disease 2019 pandemic.

The Utilization of Maternal Healthcare Services Among Ethnic Minority Populations in Vietnam

BACKGROUND

Previous studies have observed lower utilization of maternal healthcare services by ethnic minority groups in Vietnam compared with the majority Kinh community. This study sought to assess the utilization of maternal healthcare service-associated factors within 12 ethnic minority groups.

METHOD

The cross-sectional study enrolled 996 women from 12 ethnic minority groups in Vietnam in 2019. Women had pregnancy outcomes in the last 5 years. The two variables for maternal healthcare utilization were [1] a minimum of four antenatal contacts and [2] health facility-based delivery. We examined the association of individual characteristics of maternal healthcare services using multilevel modeling. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

RESULTS

This nationally representative study found that 34.1% of women from ethnic minority backgrounds had four or more antenatal contacts during pregnancy, ranging from 8.3% in Mong community to 80.2% in Cham An Giang. Most of the women (94.4%) delivered at health facilities. Factors independently correlated with having fewer than four antenatal contacts included being illiterate, early marriage, unemployment, religious affiliation, household economy, and distance to the nearest health facility. Factors significantly associated with home delivery were living in the most disadvantaged areas and having fewer than four antenatal contacts.

CONCLUSION

Substantial inequity exists in antenatal coverage both within ethnic minority groups and between socio-economic groups. The low coverage of having at least four antenatal contacts and its' correlates with facility-based delivery suggests that the government should focus efforts on increasing the number of antenatal contacts for ethnic minority women.

Factors influencing institutional delivery and the role of accredited social health activist (ASHA): a secondary analysis of India human development survey 2012

Background

India has focused on incentivizing institutional delivery and introducing the ASHA worker as a key strategy to improve maternal health outcomes. We examined the determinants of institutional delivery and the role of the ASHA worker in shaping choice regarding place of delivery.

Methods

We used data from the India Human Development Survey-II conducted in 2011–12, and extracted an analytic sample of women (N = 8711) who reported having at least one child since 2005. Logistic regression was used to examine influence of socio-demographic factors, frequency of antenatal care (ANC) contacts and exposure to ASHA worker on institutional delivery.

Results

About 15% of the respondents had eight or more ANC contacts. The odds of having an institutional delivery were higher among those respondents who had 8 or more ANC contacts (OR = 3.39, p < 0.001, 95% CI: 2.26, 5.08), and those who had 4–7 ANC contacts (OR = 1.72, p < 0.001, 95% CI: 1.48, 1.99) as compared to those with less than 4 ANC contacts. About 26% of the respondents had any exposure to an ASHA worker. After controlling for ANC contacts, these respondents had three times the odds of institutional delivery (OR = 3.04, p < 0.001, 95% CI: 2.37, 3.89) compared to those who had no exposure to ASHA workers. Further, several sociodemographic variables were associated with institutional delivery. While age of spouse, age at marriage, level of education and urban residence were positively associated with institutional delivery; age of respondent and number of children were inversely associated with institutional delivery.

Conclusions

Both frequency of ANC contacts and exposure to ASHA worker independently emerge as important determinants of institutional delivery. Furthermore, ASHA workers may have a crucial role in promoting antenatal care, thereby strengthening the association between ANC contacts and institutional delivery.

Evaluation of systems reform in public hospitals, Victoria, Australia, to improve access to antenatal care for women of refugee background: An interrupted time series design

INTRODUCTION

Inequalities in maternal and newborn health persist in many high-income countries, including for women of refugee background. The Bridging the Gap partnership programme in Victoria, Australia, was designed to find new ways to improve the responsiveness of universal maternity and early child health services for women and families of refugee background with the codesign and implementation of iterative quality improvement and demonstration initiatives. One goal of this 'whole-of-system' approach was to improve access to antenatal care. The objective of this paper is to report refugee women's access to hospital-based antenatal care over the period of health system reforms.

METHODS AND FINDINGS

The study was designed using an interrupted time series analysis using routinely collected data from two hospital networks (four maternity hospitals) at 6-month intervals during reform activity (January 2014 to December 2016). The sample included women of refugee background and a comparison group of Australian-born women giving birth over the 3 years. We describe the proportions of women of refugee background (1) attending seven or more antenatal visits and (2) attending their first hospital visit at less than 16 weeks' gestation compared over time and to Australian-born women using logistic regression analyses. In total, 10% of births at participating hospitals were to women of refugee background. Refugee women were born in over 35 countries, and at one participating hospital, 40% required an interpreter. Compared with Australian-born women, women of refugee background were of similar age at the time of birth and were more likely to be having their second or subsequent baby and have four or more children. At baseline, 60% of refugee-background women and Australian-born women attended seven or more antenatal visits. Similar trends of improvement over the 6-month time intervals were observed for both populations, increasing to 80% of women at one hospital network having seven or more visits at the final data collection period and 73% at the other network. In contrast, there was a steady decrease in the proportion of women having their first hospital visit at less than 16 weeks' gestation, which was most marked for women of refugee background. Using an interrupted time series of observational data over the period of improvement is limited compared with using a randomisation design, which was not feasible in this setting.

CONCLUSIONS

Accurate ascertainment of 'harder-to-reach' populations and ongoing monitoring of quality improvement initiatives are essential to understand the impact of system reforms. Our findings suggest that improvement in total antenatal visits may have been at the expense of recommended access to public hospital antenatal care within 16 weeks of gestation.

Efficacy of an ultrasound training program for nurse midwives to assess high-risk conditions at labor triage in rural Uganda

Many high-risk conditions of pregnancy are undetected until the time of delivery in low-income countries. We developed a point-of-care ultrasound training protocol for providers in rural Uganda to detect fetal distress or demise, malpresentation, multiple gestation, placenta previa, oligohydramnios and preterm delivery. This was a mixed-methods study to evaluate the 2-week training curriculum and trainees' ability to perform a standard scanning protocol and interpret ultrasound images. Surveys to assess provider confidence were administered pre-training, immediately after, and at 3-month follow up. Following lecture and practical demonstrations, each trainee conducted 25 proctored scans and were required to pass an observed structured clinical exam (OSCE). All images produced 8 weeks post course underwent blinded review by two ultrasound experts to assess image quality and to identify common errors. Key informant interviews further assessed perceptions of the training program and utility of point-of-care ultrasound. All interviews were audio recorded, transcribed, and reviewed by multiple readers using a content analysis approach. Twenty-three nurse/nurse midwives and two physicians from one district hospital and three health centers participated in the training curriculum. Confidence levels increased from an average of 1 point pre-course to over 6 points post-course for all measures (maximum of 7 points). Of 25 participants, 22 passed the OSCE on the first attempt (average score 89.4%). Image quality improved over time; the final error rate at week 8 was less than 5%, with an overall kappa of 0.8–1 for all measures between the two reviewers. Among the 12 key informant interviews conducted, key themes included a desire for more hands-on training and longer duration of training and challenges in balancing clinical duties with ability to attend training sessions. This study demonstrates that providers without previous ultrasound experience can detect high-risk conditions during labor with a high rate of quality and accuracy after training.

Strengths of community and health facilities based interventions in improving women and adolescents' care seeking behaviors as approaches for reducing maternal mortality and improving birth outcome among low income communities of Egypt

BACKGROUND

Provision of emergency obstetric care is considered the key for maternal mortality reduction worldwide. This study evaluated the impact of community- and facility-based educational programs on provision of emergency obstetric care in Egypt. The study focused on evaluating utilization of the available health services and care seeking behaviors of mothers in the childbearing period.

METHODS

We implemented a package of community- and facility-focused educational interventions in two of Egypt's lowest income governorates. At facility level, health professionals at rural health units from 21 villages over 5 years were trained. Mass media gathering, individual teaching at health facilities, printed materials and home-based care sessions were provided. Collectively, these interventions were designed to focusing on recognition of the early warning signs during pregnancy, delivery and postpartum period for timely referral to hospitals for 20,494 women and adolescents mothers.

RESULTS

The impact of the interventions was highly reflected on the percent of mothers received care during their pregnancy period. Proper antenatal care at governmental or private health facilities was raised dramatically from 0.6 to 59.3% and those who utilized at least one family planning method from 61.4 to 74.4%. Accordingly, the rate of complications significantly reduced during pregnancy (38.1 to 15.1%), during delivery (24.1 to 13.1%) and during postpartum (81.7 to 7.0%). As an impact to the improvement, there was a marked reduction in adolescent pregnancy by 55% and better birth outcome with a reduction in the percent of stillbirth by 11.5%.

CONCLUSION

It is important to provide a comprehensive package that works at both improving qualities of care as well as empowering women by knowledge to first aid measures at the community level. The cost-effective way to empower mothers to provide first aid measures as emergency obstetric care is to adopt the outreach approach which could be more influential than mass media campaigns for the at-risk and vulnerable and low-income communities.

Assessing the effects of maternal HIV infection on pregnancy outcomes using cross-sectional data in Malawi

BACKGROUND

Several studies have shown that maternal HIV infection is associated with adverse pregnancy outcomes such as low birth weight and perinatal mortality. However, the association is conflicted with the effect of antiretroviral therapy (ART) on the pregnancy outcomes and it remains unexamined. If the association is confirmed then it would guide policy makers towards more effective prevention of mother to child HIV transmission interventions. Using methods for matching possible confounders, the objectives of the study were to assess the effect of maternal HIV infection on birth weight and perinatal mortality and to investigate the effect of ART on these two pregnancy outcomes in HIV-infected women.

METHODS

Data on 4111 and 4759 children, born within five years of the 2010 and 2015-16 Malawi Demographic and Health Surveys (MDHS) respectively, whose mothers had an HIV test result, were analysed. A best balancing method was chosen from a set of covariate balance methods namely, the 1:1 nearest neighbour (NN) matching, matching on the propensity score (PS) and inverse weighting on the PS. HIV and ART data were only available in the MDHS 2010, permitting an assessment of the moderating effect of ART on the association between maternal HIV infection and birth weight and perinatal mortality.

RESULTS

The overall average birth weight was 3227.9g (95% CI: 3206.4, 3249.5) in 2010 and 3226.4g (95%: 3205.6, 3247.2) in 2015-16 and perinatal mortality was 3.8% (95%: 3.2, 4.3) in 2010 and 3.5% (95%: 2.8, 3.8) in 2015-16. The prevalence of HIV among the mothers was 11.1% (95%: 10.1, 12.0) and 9.2% (95% CI: 8.4, 10.1) in 2010 and 2015-16, respectively. In 2010, maternal HIV infection was negatively associated with birth weight (mean= -25.3g, 95% CI:(-95.5, -7.4)) and in 2015-16 it was positively associated with birth weight (mean= 116.3g, 95% CI:(27.8, 204.7)). Perinatal mortality was higher in infants of HIV-infected mothers compared to infants of HIV-uninfected mothers (OR = 1.5, 95% CI:(1.1 - 3.1)) in 2010, while there was no difference in the rate in 2015-16 (OR = 1.0, 95% CI:(0.4, 1.6)). ART was not associated with birth weight, however, it was associated with perinatal mortality (OR=3.9, 95% CI:(1.1, 14.8)).

CONCLUSION

The study has found that maternal HIV infection had an adverse effect on birth weight and perinatal mortality in 2010. Birth weight was not dependent on ART uptake but perinatal mortality was higher among infants of HIV-infected mothers who were not on ART. The higher birth weight among HIV-infected mothers and similarity in perinatal mortality with HIV-uninfected mothers in 2015-16 may be indicative of successes of interventions within the PMTCT program in Malawi.

Systematic review of the measurement properties of indices of prenatal care utilization

Background

An accurate assessment of the adequacy of prenatal care utilization is critical to inform the relationship between prenatal care and pregnancy outcomes. This systematic review critically appraises the evidence on measurement properties of prenatal care utilization indices and provides recommendations about which index is the most useful for this purpose.

Methods

MEDLINE, EMBASE, CINAHL, and Web of Science were systematically searched from database inception to October 2018 using keywords related to indices of prenatal care utilization. No language restrictions were imposed. Studies were included if they evaluated the reliability, validity, or responsiveness of at least one index of adequacy of prenatal care utilization. We used the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. We conducted an evidence synthesis using predefined criteria to appraise the measurement properties of the indices.

Results

From 2664 studies initially screened, 13 unique studies evaluated the measurement properties of at least one index of prenatal care utilization. Most of the indices of adequacy of prenatal care currently used in research and clinical practice have been evaluated for at least some form of reliability and/or validity. Evidence about the responsiveness to change of these indices is absent from these evaluations. The Adequacy Perinatal Care Utilization Index (APNCUI) and the Kessner Index are supported by moderate evidence regarding their reliability, predictive and concurrent validity.

Conclusion

The scientific literature has not comprehensively reported the measurement properties of commonly used indices of prenatal care utilization, and there is insufficient research to inform the choice of the best index. Lack of strong evidence about which index is the best to measure prenatal care utilization has important implications for tracking health care utilization and for formulating prenatal care recommendations.

Happy Mother's Day? Maternal and neonatal mortality and morbidity in low- and middle-income countries

At least 800 women die each day during pregnancy or birth and more than 15 000 babies each day are stillborn or die in the first month of life. Almost all of these deaths occur in low- and middle-income countries. Many more women and babies are known to suffer morbidity as a result of pregnancy and childbirth. However, reliable estimates of the burden of physical, psychological and social morbidity and comorbidity during and after pregnancy are not available. Although there is no single intervention or ‘magic bullet’ that would reduce mortality and improve health, there are evidence-based care packages which are defined and agreed internationally. A functioning health system with care available and accessible for everyone at all times is required to ensure women and babies survive and thrive.

Antenatal and intrapartum interventions for reducing caesarean section, promoting vaginal birth, and reducing fear of childbirth: An overview of systematic reviews

Concern has been expressed globally over rising caesarean birth rates. Recently, the International Federation of Gynaecology and Obstetrics (FIGO) called for help from governmental bodies, professional organisations, women’s groups, and other stakeholders to reduce unnecessary caesareans. As part of a wider research initiative, we conducted an overview of systematic reviews of antenatal and intrapartum interventions, and reports of evidence based recommendations, to identify and highlight those that have been shown to be effective for reducing caesarean birth, promoting vaginal birth and reducing fear of childbirth. Following registration of the review protocol, (PROSPERO 2018 CRD42018090681), we searched The Cochrane Database of Systematic Reviews, PubMed, CINAHL and EMBASE (Jan 2000-Jan 2018) and searched for grey literature in PROSPERO, and on websites of health professional and other relevant bodies. Screening and selection of reviews, quality appraisal using AMSTAR-2, and data extraction were performed independently by pairs of at least two reviewers. Excluding reviews assessed as ‘critically low’ on AMSTAR-2 (n = 54), 101 systematic reviews, and 10 reports of evidence based recommendations were included in the overview. Narrative synthesis was performed, due to heterogeneity of review methodology and topics. The results highlight twenty-five interventions, across 17 reviews, that reduced the risk of caesarean, nine interventions across eight reviews that increased the risk of caesarean, eight interventions that reduced instrumental vaginal birth, four interventions that increased spontaneous vaginal birth, and two interventions that reduced fear of childbirth. This overview of reviews identifies and highlights interventions that have been shown to be effective for reducing caesarean birth, promoting vaginal births and reducing fear of childbirth. In recognising that clinical practices change over time, this overview includes reviews published from 2000 onwards only, thus providing contemporary evidence, and a valuable resource for clinicians when making decisions on practices that should be implemented for reducing unnecessary caesarean births safely.

Protocol Registration: PROSPERO 2018 CRD42018090681. Available from: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018090681

Targeting Pregnant Women for Malaria Surveillance

Women attending antenatal care (ANC) are a generally healthy, easy-access population, contributing valuable data for infectious disease surveillance at the community level. ANC-based malaria surveillance would provide a routine measure of the malaria burden in pregnancy, which countries lack, whilst potentially improving pregnancy outcomes. It could also offer contemporary information on temporal trends and the geographic distribution of malaria burden as well as intervention coverage in the population to guide resource allocation and to assess progress towards elimination. Here, we review the factors underlying the relationship between Plasmodium falciparum in pregnancy and in the community, and outline strengths and limitations of an ANC-based surveillance in sub-Saharan Africa, its potential role within wider malaria surveillance systems, and subsequent programmatic applications.

Provision and uptake of routine antenatal services: a qualitative evidence synthesis

BACKGROUND

Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes.This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future.

OBJECTIVES

To identify, appraise, and synthesise qualitative studies exploring:· Women's views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women's accounts;· Healthcare providers' views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers.

SEARCH METHODS

To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase.

SELECTION CRITERIA

We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided.We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education.

DATA COLLECTION AND ANALYSIS

Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta-ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE-CERQual. We used these findings to generate higher-level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane effectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour.

MAIN RESULTS

We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. We developed 52 findings in total and organised these into three thematic domains: socio-cultural context (11 findings, five moderate- or high-confidence); service design and provision (24 findings, 15 moderate- or high-confidence); and what matters to women and staff (17 findings, 11 moderate- or high-confidence) The third domain was sub-divided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using high- or moderate-confidence findings:For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good-quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women's need for privacy, and that allow staff to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women's perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio-cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time.The capacity of healthcare providers to deliver the kind of high-quality, relationship-based, locally accessible ANC that is likely to facilitate access by women depends on the provision of sufficient resources and staffing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring staff who make effective, culturally-appropriate links with local communities, who respect women's belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require sufficient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies.

AUTHORS' CONCLUSIONS

This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good-quality ANC by healthcare providers. It complements existing effectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.

Prenatal care in Southern Brazil: coverage, trend and disparities

OBJECTIVE

To estimate coverage, examine trend and assess the disparity reduction regarding household income during prenatal care between mothers living in Rio Grande, state of Rio Grande do Sul, in 2007, 2010, 2013 and 2016.

METHODS

This study included all recent mothers living in this municipality, between 1/1 and 12/31 of those years, who had a child weighing more than 500 grams or 20 weeks of gestational age in one of the only two local maternity hospitals. Trained interviewers applied, still in the hospital and up to 48 hours after delivery, a unique and standardized questionnaire, seeking to investigate maternal demographic and reproductive characteristics, the socioeconomic conditions of the family and the assistance received during pregnancy and childbirth. To assess the adequacy of prenatal care, the criteria proposed by Takeda were used, which considers only the number of prenatal appointments and gestational age at initiation, and by Silveira et al., who in addition to these two variables, considers the achievement of some laboratory tests. Chi-square tests were used to compare proportions and assess the linear trend.

RESULTS

The total of 10,669 recent mothers were included in this survey (96.8% of the total). Prenatal coverage substantially increased between 2007 and 2016. According to Takeda, it rose from 69% to 80%, while for Silveira et al., it increased from 21% to 55%. This improvement occurred for all income groups (p < 0.01). The disparity between the extreme categories of income reduced, according to Takeda, and increased according to Silveira et al.

CONCLUSIONS

The provision of prenatal care, considering only the number of appointments and the early start, occurred in greater proportion among the poorest. However, only the richest recent mothers were contemplated with more elaborate care, such as laboratory tests, which increased the disparities in the provision of prenatal care.

Examining the impact of WHO's Focused Antenatal Care policy on early access, underutilisation and quality of antenatal care services in Malawi: a retrospective study

Background

A variety of antenatal care models have been implemented in low and middle-income countries over the past decades, as proposed by the World Health Organisation (WHO). One such model is the 2001 Focused Antenatal Care (FANC) programme. FANC recommended a minimum of four visits for women with uncomplicated pregnancies and emphasised quality of care to improve both maternal and neonatal outcomes. Malawi adopted FANC in 2003, however, up to now no study has been done to analyse the model’s performance with regards to antenatal care service quality and utilisation patterns.

Methods

The paper is based on data pooled from three comparable nationally representative Malawi Demographic and Health Survey (MDHS) datasets (2000, 2004 and 2010). The DHS collects data on demographics, socio-economic indicators, antenatal care, and the fertility history of reproductive women aged between 15 and 49. We pooled a sample of 8545 women who had a live birth in the last 5 years prior to each survey. We measure the impact of FANC on early access to care, underutilisation of care and quality of care with interrupted time series analysis. This method enables us to track changes in both levels and the trends of our outcome variables.

Results

We find that FANC is associated with earlier access to care. However, it has also been associated with unintended increases in underutilisation. We see no change in the quality of ANC services.

Conclusion

In light of the WHO 2016 ANC guidelines, which recommend an increase of visits to eight, these results are important. Given that we find underutilisation when the benchmark is set at four visits, eight visits are unlikely to be feasible in low-resource settings.

Perceptions of postoutbreak management by management and healthcare workers of a Middle East respiratory syndrome outbreak in a tertiary care hospital: a qualitative study

OBJECTIVES

This study examines perceptions of the operational and organisational management of a major outbreak of Middle East Respiratory Syndrome (MERS) caused by a novel coronavirus (MERS-CoV) in the Kingdom of Saudi Arabia (KSA). Perspectives were sought from key decision-makers and clinical staff about the factors perceived to promote and inhibit effective and rapid control of the outbreak.

SETTING

A large teaching tertiary healthcare centre in KSA; the outbreak lasted 6 weeks from June 2015.

PARTICIPANTS

Data were collected via individual and focus group interviews with 28 key informant participants (9 management decision-makers and 19 frontline healthcare workers).

DESIGN

We used qualitative methods of process evaluation to examine perceptions of the outbreak and the factors contributing to, or detracting from successful management. Data were analysed using qualitative thematic content analysis.

RESULTS

Five themes and 15 subthemes were found. The themes were related to: (1) the high stress of the outbreak, (2) factors perceived to contribute to outbreak occurrence, (3) factors perceived to contribute to success of outbreak control, (4) factors inhibiting outbreak control and (5) long-term institutional gains in response to the outbreak management.

CONCLUSION

Management of the MERS-CoV outbreak at King Abdulaziz Medical City-Riyadh was widely recognised by staff as a serious outbreak of local and national significance. While the outbreak was controlled successfully in 6 weeks, progress in management was inhibited by a lack of institutional readiness to implement infection control (IC) measures and reduce patient flow, low staff morale and high anxiety. Effective management was promoted by greater involvement of all staff in sharing learning and knowledge of the outbreak, developing trust and teamwork and harnessing collective leadership. Future major IC crises could be improved via measures to strengthen these areas, better coordination of media management and proactive staff counselling and support.

Use of wearable sensors for pregnancy health and environmental monitoring: Descriptive findings from the perspective of patients and providers

Background

Wearable sensors and other smart technology may be especially beneficial in providing remote monitoring of sub-clinical changes in pregnancy health status. Yet, limited research has examined perceptions among pregnant patients and providers in incorporating smart technology into their daily routine and clinical practice.

Objective

The purpose of this study was to examine the perceptions of pregnant women and their providers at a rural health clinic on the use of wearable technology to monitor health and environmental exposures during pregnancy.

Methods

An anonymous 21-item e-survey was administered to family medicine or obstetrics and gynecology (n=28) providers at a rural health clinic; while a 21-item paper survey was administered to pregnant women (n=103) attending the clinic for prenatal care.

Results

Smartphone and digital technology use was high among patients and providers. Patients would consider wearing a mobile sensor during pregnancy, reported no privacy concerns, and felt comfortable sharing information from these devices with their physician. About seven out of 10 women expressed willingness to change their behavior during pregnancy in response to receiving personalized recommendations from a smartphone. While most providers did not currently use smart technologies in their medical practice, about half felt it will be used more often in the future to diagnose and remotely monitor patients. Patients ranked fetal heart rate and blood pressure as their top preference for health monitoring compared to physicians who ranked blood pressure and blood glucose. Patients and providers demonstrated similar preferences for environmental monitoring, but patients as a whole expressed more interests in tracking environmental measures compared to their providers.

Conclusions

Patients and providers responded positively to the use of wearable sensor technology in prenatal care. More research is needed to understand what factors might motivate provider use and implementation of wearable technology to improve the delivery of prenatal care.

Role of Qualified Physicians as Antenatal Care Providers in Reducing Birth Complications in Home-delivered Rural Women in Bangladesh

Introduction Bangladesh has made significant strides in maternal and neonatal death by ensuring qualified antenatal care (ANC) visits during the pregnancy period of women. To ensure this qualified ANC, the government of Bangladesh has increased the number of qualified physicians and skilled birth attendants at health facilities and encouraged pregnant women to take this eligible ANC during pregnancy. Despite this progress, the majority of deliveries among rural women still occur at home, assisted by traditional birth attendants. These traditional birth attendants at home or even skilled birth attendants at the health facility or home are not always cable of helping women to overcome severe delivery complications. Proper birth preparation before pregnancy through qualified ANC might be a solution here. Taking advice for appropriate birth preparation from a qualified physician (medical doctor) would ensure qualified ANC. In this study, we examined how ANC from a qualified physician, as compared to other trained providers, influences rural women delivering at home to prepare for birth and reduces severe delivery complications. Methods The data of 1554 rural women who delivered at home were extracted from the 2014 Bangladesh Demographic and Health Survey data. A mixed-effects logistic regression model was carried out for the binary delivery complications data, to assess the influence of qualified physicians as ANC providers on delivery complications by adjusting the effect of other socio-demographic covariates and clustering. Results Of the women from rural areas who delivered at home, 42% reported delivery complications. Those who received ANC from a qualified physician were 32% less likely (OR 0.68; 95% CI 0.50, 0.91) to report facing delivery complications as compared to those who had received ANC from other trained or unqualified providers adjusted by socio-demographic determinants in Bangladesh. Conclusions Developing a sustained and effective strategy could be a precedent for promoting ANC from qualified physicians for rural women delivering at home, to decrease delivery complications as well as creating healthy environments for safe deliveries.

Taking account of context in systematic reviews and guidelines considering a complexity perspective

Systematic review teams and guideline development groups face considerable challenges when considering context within the evidence production process. Many complex interventions are context-dependent and are frequently evaluated within considerable contextual variation and change. This paper considers the extent to which current tools used within systematic reviews and guideline development are suitable in meeting these challenges. The paper briefly reviews strengths and weaknesses of existing approaches to specifying context. Illustrative tools are mapped to corresponding stages of the systematic review process. Collectively, systematic review and guideline production reveals a rich diversity of frameworks and tools for handling context. However, current approaches address only specific elements of context, are derived from primary studies which lack information or have not been tested within systematic reviews. A hypothetical example is used to illustrate how context could be integrated throughout the guideline development process. Guideline developers and evidence synthesis organisations should select an appropriate level of contextual detail for their specific guideline that is parsimonious and yet sensitive to health systems contexts and the values, preferences and needs of their target populations.

Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews

BACKGROUND

Preterm birth (PTB) is a major factor contributing to global rates of neonatal death and to longer-term health problems for surviving infants. Both the World Health Organization and the United Nations consider prevention of PTB as central to improving health care for pregnant women and newborn babies. Current preventative clinical strategies show varied efficacy in different populations of pregnant women, frustrating women and health providers alike, while researchers call for better understanding of the underlying mechanisms that lead to PTB.

OBJECTIVES

We aimed to summarise all evidence for interventions relevant to the prevention of PTB as reported in Cochrane systematic reviews (SRs). We intended to highlight promising interventions and to identify SRs in need of an update.

METHODS

We searched the Cochrane Database of Systematic Reviews (2 November 2017) with key words to capture any Cochrane SR that prespecified or reported a PTB outcome. Inclusion criteria focused on pregnant women without signs of preterm labour or ruptured amniotic membranes. We included reviews of interventions for pregnant women irrespective of their risk status. We followed standard Cochrane methods.We applied GRADE criteria to evaluate the quality of SR evidence. We assigned graphic icons to classify the effectiveness of interventions as: clear evidence of benefit; clear evidence of harm; clear evidence of no effect or equivalence; possible benefit; possible harm; or unknown benefit or harm. We defined clear evidence of benefit and clear evidence of harm to be GRADE moderate- or high-quality evidence with a confidence interval (CI) that does not cross the line of no effect. Clear evidence of no effect or equivalence is GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect. Possible benefit and possible harm refer to GRADE low-quality evidence with a clear effect (CI does not cross the line of no effect) or GRADE moderate- or high-quality evidence with a wide CI. Unknown harm or benefit refers to GRADE low- or very low-quality evidence with a wide CI.

MAIN RESULTS

We included 83 SRs; 70 had outcome data. Below we highlight key results from a subset of 36 SRs of interventions intended to prevent PTB.

OUTCOME

preterm birthClear evidence of benefitFour SRs reported clear evidence of benefit to prevent specific populations of pregnant women from giving birth early, including midwife-led continuity models of care versus other models of care for all women; screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection; and zinc supplementation for pregnant women without systemic illness. Cervical cerclage showed clear benefit for women with singleton pregnancy and high risk of PTB only.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, bedrest for women with singleton pregnancy and antibiotic prophylaxis during the second and third trimester were of no effect or equivalent to a comparator.Possible benefitFour SRs found possible benefit in: group antenatal care for all pregnant women; antibiotics for pregnant women with asymptomatic bacteriuria; pharmacological interventions for smoking cessation for pregnant women who smoke; and vitamin D supplements alone for women without pre-existing conditions such as diabetes.Possible harmOne SR reported possible harm (increased risk of PTB) with intramuscular progesterone, but this finding is only relevant to women with multiple pregnancy and high risk of PTB. Another review found possible harm with vitamin D, calcium and other minerals for pregnant women without pre-existing conditions.

OUTCOME

perinatal deathClear evidence of benefitTwo SRs reported clear evidence of benefit to reduce pregnant women's risk of perinatal death: midwife-led continuity models of care for all pregnant women; and fetal and umbilical Doppler for high-risk pregnant women.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, antibiotic prophylaxis during the second and third trimester was of no effect or equivalent to a comparator.Possible benefitOne SR reported possible benefit with cervical cerclage for women with singleton pregnancy and high risk of PTB.Possible harmOne SR reported possible harm associated with a reduced schedule of antenatal visits for pregnant women at low risk of pregnancy complications; importantly, these women already received antenatal care in settings with limited resources.

OUTCOMES

preterm birth and perinatal deathUnknown benefit or harmFor pregnant women at high risk of PTB for any reason including multiple pregnancy, home uterine monitoring was of unknown benefit or harm. For pregnant women at high risk due to multiple pregnancy: bedrest, prophylactic oral betamimetics, vaginal progesterone and cervical cerclage were all of unknown benefit or harm.

AUTHORS' CONCLUSIONS

Implications for practiceThe overview serves as a map and guide to all current evidence relevant to PTB prevention published in the Cochrane Library. Of 70 SRs with outcome data, we identified 36 reviews of interventions with the aim of preventing PTB. Just four of these SRs had evidence of clear benefit to women, with an additional four SRs reporting possible benefit. No SR reported clear harm, which is an important finding for women and health providers alike.The overview summarises no evidence for the clinically important interventions of cervical pessary, cervical length assessment and vaginal progesterone because these Cochrane Reviews were not current. These are active areas for PTB research.The graphic icons we assigned to SR effect estimates do not constitute clinical guidance or an endorsement of specific interventions for pregnant women. It remains critical for pregnant women and their healthcare providers to carefully consider whether specific strategies to prevent PTB will be of benefit for individual women, or for specific populations of women.Implications for researchFormal consensus work is needed to establish standard language for overviews of reviews and to define the limits of their interpretation.Clinicians, researchers and funders must address the lack of evidence for interventions relevant to women at high risk of PTB due to multiple pregnancy.

Determinants of antenatal care attendance among women residing in highly disadvantaged communities in northern Jordan: a cross-sectional study

BACKGROUND

One of the major reproductive health challenges among disadvantaged populations is to provide pregnant women with the necessary antenatal care (ANC). In this study, we suggest applying an integrated conceptual framework aimed at ascertaining the extent to which attendance at ANC clinics may be attributed to individual determinants or to the quality of the care received.

METHODS

Using a cross-sectional design, data were collected from a sample of 831 women residing in nine sub-districts in three northern governorates of Jordan and designated according to national categorization as persistent poverty pockets. All of the sampled women were recruited from public maternal and child health centers and interviewed using a structured pre-tested survey. This tool covered certain predictors, ranging from the user's attributes, including predisposing, enabling, and need factors, to the essential components of the experience of care. These components assessed the quality of ANC in terms of five elements: woman-provider relations, technical management, information exchange, continuity of care, and appropriate constellation of services. Adequate ANC content was assessed in relation to the frequency of antenatal visits and the time of each visit.

RESULTS

The results of multivariate logistic regression analyses show that the use of ANC facilities is affected by various factors related to the quality of service delivery. These include receiving information and education on ANC during clinic visits (OR = 9.1; 95% CI = 4.9-16.9), providing pregnant women with opportunities for dialogue and health talks (OR = 7.2; 95% CI = 4.1-12.8), having scheduled follow-up appointments (OR = 6.5; 95% CI = 3.5-12.0), and offering dignified and respectful care (OR = 5.7; 95% CI = 2.5-13.1). At the individual level, our findings have identified a woman's education level (OR = 1.2; 95% CI = 1.1-1.3), desire for the pregnancy (OR = 1.7; 95% CI = 1.1-2.7), and living in a district served by an ANC clinic (OR = 4.3; 95% CI = 2.3-8.1) as determinants affecting ANC utilization.

CONCLUSION

Taking women's experiences of ANC as a key metric for reporting the quality of the care is more likely to lead to increased utilization of ANC services by women in highly disadvantaged communities. Our findings suggest that the degree to which women feel that they are respected, informed, and engaged in their care has potential favorable implications for ANC.

Reference ranges of the WHO Disability Assessment Schedule (WHODAS 2.0) score and diagnostic validity of its 12-item version in identifying altered functioning in healthy postpartum women

OBJECTIVES

To compare scores on the 36-item WHO Disability Assessment Schedule 2.0 tool (WHODAS-36) for postpartum women across a continuum of morbidity and to validate the 12-item version (WHODAS-12).

METHODS

This is a secondary analysis of the Brazilian retrospective cohort study on long-term repercussions of severe maternal morbidity. We determined mean, median, and percentile values for WHODAS-36 total score and for each domain, and percentile values for WHODAS-12 total score in postpartum women divided into three groups: "no," "nonsevere," and "severe" morbidities.

RESULTS

The WHODAS-36 mean total scores were 11.58, 18.31, and 19.19, respectively for no, nonsevere, and severe morbidity. There was a dose-dependent effect on scores for each domain of WHODAS-36 according to the presence and severity of morbidity. The diagnostic validity of WHODAS-12 was determined by comparing it with WHODAS-36 as a "gold standard." The best cut-off point for diagnosing dysfunctionality was the 95th percentile.

CONCLUSION

The upward trend of WHODAS-36 total mean value scores of women with no morbidity compared with those with morbidity along a severity continuum may reflect the impact of morbidity on postpartum functioning.

Can a midwife-led continuity model improve maternal services in a low-resource setting? A non-randomised cluster intervention study in Palestine

OBJECTIVES

To improve maternal health services in rural areas, the Palestinian Ministry of Health launched a midwife-led continuity model in the West Bank in 2013. Midwives were deployed weekly from governmental hospitals to provide antenatal and postnatal care in rural clinics. We studied the intervention's impact on use and quality indicators of maternal services after 2 years' experience.

DESIGN

A non-randomised intervention design was chosen. The study was based on registry data only available at cluster level, 2 years before (2011and2012) and 2 years after (2014and2015) the intervention.

SETTING

All 53 primary healthcare clinics in Nablus and Jericho regions were stratified for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome was number of antenatal visits. Important secondary outcomes were number of referrals to specialist care and number of postnatal home visits. Differences in changes within the two groups before and after the intervention were compared by using mixed effect models.

RESULTS

14 intervention clinics and 25 control clinics were included. Number of antenatal visits increased by 1.16 per woman in the intervention clinics, while declined by 0.39 in the control clinics, giving a statistically significant difference in change of 1.55 visits (95% CI 0.90 to 2.21). A statistically significant difference in number of referrals was observed between the groups, giving a ratio of rate ratios of 3.65 (2.78-4.78) as number of referrals increased by a rate ratio of 3.87 in the intervention group, while in the control the rate ratio was only 1.06.Home visits increased substantially in the intervention group but decreased in the control group, giving a ratio of RR 97.65 (45.20 - 210.96) CONCLUSION: The Palestinian midwife-led continuity model improved use and some quality indicators of maternal services. More research should be done to investigate if the model influenced individual health outcomes and satisfaction with care.

TRIAL REGISTRATION NUMBER

NCT03145571; Results.

Timing of maternal death: Levels, trends, and ecological correlates using sibling data from 34 sub-Saharan African countries

Millennium Development Goal 5 has not been universally achieved, particularly in sub-Saharan Africa. Understanding whether maternal deaths occur during pregnancy, childbirth, or puerperium is important to effectively plan maternal health programs and allocate resources. Our main research objectives are to (1) describe the proportions and rates of mortality for the antepartum, intrapartum, and postpartum periods; (2) document how these trends vary by sub-region; and (3) investigate ecological correlations between these rates and maternal care interventions. We used data from the Demographic and Health Survey program, which comprises 84 surveys from 34 sub-Saharan African countries conducted between 1990 and 2014. We calculated age-standardized maternal mortality rates and time-specific maternal mortality rates and proportions, and we assessed correlations with maternal care coverage. We found high levels of maternal mortality in all three periods. Time-specific maternal mortality rates varied by country and region, with some showing an orderly decline in all three periods and others exhibiting alarming increases in antepartum and postpartum mortality. Ecological analysis showed that antenatal care coverage was significantly associated with low antepartum mortality, whereas the presence of a skilled attendant at childbirth was significantly associated with low postpartum mortality. In sub-Saharan Africa, maternal deaths occur at high rates in all three risk periods, and vary substantially by country and region. The provision of maternal care is a predictor of time-specific maternal mortality. These results confirm the need for country-specific interventions during the continuum of care to achieve the global commitment to eliminating preventable maternal mortality.

Epidural therapy for the treatment of severe pre-eclampsia in non labouring women

BACKGROUND

Pre-eclampsia is a pregnancy-specific multi-organ disorder, which is characterised by hypertension and multisystem organ involvement and which has significant maternal and fetal morbidity and mortality. Failure of the placental vascular remodelling and reduced uteroplacental flow form the etiopathological basis of pre-eclampsia. There are several established therapies for pre-eclampsia including antihypertensives and anticonvulsants. Most of these therapies aim at controlling the blood pressure or preventing complications of elevated blood pressure, or both. Epidural therapy aims at blocking the vasomotor tone of the arteries, thereby increasing uteroplacental blood flow. This review was aimed at evaluating the available evidence about the possible benefits and risks of epidural therapy in the management of severe pre-eclampsia, to define the current evidence level of this therapy, and to determine what (if any) further evidence is required.

OBJECTIVES

To assess the effectiveness, safety and cost of the extended use of epidural therapy for treating severe pre-eclampsia in non-labouring women. This review aims to compare the use of extended epidural therapy with other methods, which include intravenous magnesium sulphate, anticonvulsants other than magnesium sulphate, with or without use of the antihypertensive drugs and adjuncts in the treatment of severe pre-eclampsia.This review only considered the use of epidural anaesthesia in the management of severe pre-eclampsia in the antepartum period and not as pain relief in labour.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (13 July 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing epidural therapy versus traditional therapy for pre-eclampsia in the form of antihypertensives, anticonvulsants, magnesium sulphate, low-dose dopamine, corticosteroids or a combination of these, were eligible for inclusion. Trials using a cluster design, and studies published in abstract form only are also eligible for inclusion in this review. Cross-over trials were not eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

The two review authors independently assessed trials for inclusion and trial quality. There were no relevant data available for extraction.

MAIN RESULTS

We included one small study (involving 24 women). The study was a single-centre randomised trial conducted in Mexico. This study compared a control group who received antihypertensive therapy, anticonvulsant therapy, plasma expanders, corticosteroids and dypyridamole with an intervention group that received epidural block instead of the antihypertensives, as well as all the other four drugs. Lumbar epidural block was given using 0.25% bupivacaine, 10 mg bolus and 5 mg each hour on continuous epidural infusion for six hours. This study was at low risk of bias in three domains but was assessed to be high risk of bias in two domains due to lack of allocation concealment and blinding of women and staff, and unclear for random sequence generation and outcome assessor blinding.The included study did not report on any of this review's important outcomes. Meta-analysis was not possible.For the mother, these were: maternal death (death during pregnancy or up to 42 days after the end of the pregnancy, or death more than 42 days after the end of the pregnancy); development of eclampsia or recurrence of seizures; stroke; any serious morbidity: defined as at least one of stroke, kidney failure, liver failure, HELLP syndrome (haemolysis, elevated liver enzymes and low platelets), disseminated intravascular coagulation, pulmonary oedema.For the baby, these were: death: stillbirths (death in utero at or after 20 weeks' gestation), perinatal deaths (stillbirths plus deaths in the first week of life), death before discharge from the hospital, neonatal deaths (death within the first 28 days after birth), deaths after the first 28 days; preterm birth (defined as the birth before 37 completed weeks' gestation); and side effects of the intervention. Reported outcomesThe included study only reported on a single secondary outcome of interest to this review: the Apgar score of the baby at birth and after five minutes and there was no clear difference between the intervention and control groups.The included study also reported a reduction in maternal diastolic arterial pressure. However, the change in maternal mean arterial pressure and systolic arterial pressure, which were the other reported outcomes of this trial, were not significantly different between the two groups.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence from randomised controlled trials to evaluate the effectiveness, safety or cost of using epidural therapy for treating severe pre-eclampsia in non-labouring women.High-quality randomised controlled trials are needed to evaluate the use of epidural agents as therapy for treatment of severe pre-eclampsia. The rationale for the use of epidural is well-founded. However there is insufficient evidence from randomised controlled trials to show that the effect of epidural translates into improved maternal and fetal outcomes. Thus, there is a need for larger, well-designed studies to come to an evidence-based conclusion as to whether the lowering of vasomotor tone by epidural therapy results in better maternal and fetal outcomes and for how long that could be maintained. Another important question that needs to be answered is how long should extended epidural be used to ensure any potential clinical benefits and what could be the associated side effects and costs. Interactions with other modalities of treatment and women's satisfaction could represent other avenues of research.

Antenatal care services and its implications for vital and health outcomes of children: evidence from 193 surveys in 69 low-income and middle-income countries

OBJECTIVES

Antenatal care (ANC) is an essential part of primary healthcare and its provision has expanded worldwide. There is limited evidence of large-scale cross-country studies on the impact of ANC offered to pregnant women on child health outcomes. We investigate the association of ANC in low-income and middle-income countries with short- and long-term mortality and nutritional child outcomes.

SETTING

We used nationally representative health and welfare data from 193 Demographic and Health Surveys conducted between 1990 and 2013 from 69 low-income and middle-income countries for women of reproductive age (15-49 years), their children and their respective household.

PARTICIPANTS

The analytical sample consisted of 752 635 observations for neonatal mortality, 574 675 observations for infant mortality, 400 426 observations for low birth weight, 501 484 observations for stunting and 512 424 observations for underweight.

MAIN OUTCOMES AND MEASURES

Outcome variables are neonatal and infant mortality, low birth weight, stunting and underweight.

RESULTS

At least one ANC visit was associated with a 1.04% points reduced probability of neonatal mortality and a 1.07% points lower probability of infant mortality. Having at least four ANC visits and having at least once seen a skilled provider reduced the probability by an additional 0.56% and 0.42% points, respectively. At least one ANC visit is associated with a 3.82% points reduced probability of giving birth to a low birth weight baby and a 4.11 and 3.26% points reduced stunting and underweight probability. Having at least four ANC visits and at least once seen a skilled provider reduced the probability by an additional 2.83%, 1.41% and 1.90% points, respectively.

CONCLUSIONS

The currently existing and accessed ANC services in low-income and middle-income countries are directly associated with improved birth outcomes and longer-term reductions of child mortality and malnourishment.

Role of LIF Cytokine and CD34 Angiogenesis Marker in Non-Developing Pregnancy

The expression of cytokine LIF (leukemia inhibiting factor) in the endometrium of women of young reproductive age with non-developing pregnancy of unknown genesis is higher than in older women and women with infection-related miscarriages by 1.26 and 1.43 times, respectively. The expression of angiogenesis marker CD34 in the endometrium of young women with non-developing pregnancy of unknown origin is 1.59 times higher and in case of endometrial inflammation 1.31 times higher than in women of the older reproductive age with the same disease. Correlation between the endometrial expression of LIF and CD34 is detected in women of the younger reproductive age with non-developing pregnancy of unknown etiology. The expression of LIF and CD34 can be used for endometrial function evaluation in women of different age with first trimester non-developing pregnancy.

Preventing deaths due to the hypertensive disorders of pregnancy

In this chapter, taking a life cycle and both civil society and medically oriented approach, we will discuss the contribution of the hypertensive disorders of pregnancy (HDPs) to maternal, perinatal and newborn mortality and morbidity. Here we review various interventions and approaches to preventing deaths due to HDPs and discuss effectiveness, resource needs and long-term sustainability of the different approaches. Societal approaches, addressing sustainable development goals (SDGs) 2.2 (malnutrition), 3.7 (access to sexual and reproductive care), 3.8 (universal health coverage) and 3c (health workforce strengthening), are required to achieve SDGs 3.1 (maternal survival), 3.2 (perinatal survival) and 3.4 (reduced impact of non-communicable diseases (NCDs)). Medical solutions require greater clarity around the classification of the HDPs, increased frequency of effective antenatal visits, mandatory responses to the HDPs when encountered, prompt provision of life-saving interventions and sustained surveillance for NCD risk for women with a history of the HDPs.

Content of antenatal care: Does it prepare women for birth?

OBJECTIVE

clinical guidelines for antenatal care recommend informing women about birth. The aim of this study was to explore the content of antenatal care from women's perspective and to establish whether they consider information on birth to be sufficient.

METHOD

the data was gathered in a longitudinal, cross-sectional cohort study known as The Childbirth and Health Study in Iceland. The study group consisted of 765 women attending antenatal care at 26 urban and rural health care centres in Iceland, during the year 2009-2010. They participated by replying to two questionnaires, at 16 gestational weeks and six months after birth. The questions covered objective and subjective aspects of antenatal care, pregnancy, birth, and the postpartum period.

RESULTS

the majority (87%) of the women want to be informed about birth in the antenatal phase of care, and 41% reported 5-6 months post partum that too little time had been spent on this issue, by health care professionals. Post partum, mode of delivery affected women's estimated time spent on information in pregnancy, with women who had planned caesarean section being most satisfied with the time spent on antenatal information about birth. Women who experienced their birth as difficult or very difficult were more likely to report that insufficient time had been spent on information than women who had experienced their birth as easy or very easy.

CONCLUSIONS

antenatal care can play an important role in preparing women for birth. This study shows that information about birth provided during pregnancy is insufficient from women's perspective, although some groups of women do report being more satisfied with this information. The way that this segment of antenatal care is provided leaves room for improvement.

Health system and community level interventions for improving antenatal care coverage and health outcomes

BACKGROUND

The World Health Organization (WHO) recommends at least four antenatal care (ANC) visits for all pregnant women. Almost half of pregnant women worldwide, and especially in developing countries do not receive this amount of care. Poor attendance of ANC is associated with delivery of low birthweight babies and more neonatal deaths. ANC may include education on nutrition, potential problems with pregnancy or childbirth, child care and prevention or detection of disease during pregnancy.This review focused on community-based interventions and health systems-related interventions.

OBJECTIVES

To assess the effects of health system and community interventions for improving coverage of antenatal care and other perinatal health outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised trials and cluster-randomised trials. Trials of any interventions to improve ANC coverage were eligible for inclusion. Trials were also eligible if they targeted specific and related outcomes, such as maternal or perinatal death, but also reported ANC coverage.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included 34 trials involving approximately 400,000 women. Some trials tested community-based interventions to improve uptake of antenatal care (media campaigns, education or financial incentives for pregnant women), while other trials looked at health systems interventions (home visits for pregnant women or equipment for clinics). Most trials took place in low- and middle-income countries, and 29 of the 34 trials used a cluster-randomised design. We assessed 30 of the 34 trials as of low or unclear overall risk of bias. Comparison 1: One intervention versus no interventionWe found marginal improvements in ANC coverage of at least four visits (average odds ratio (OR) 1.11, 95% confidence interval (CI) 1.01 to 1.22; participants = 45,022; studies = 10; Heterogeneity: Tau² = 0.01; I² = 52%; high quality evidence). Sensitivity analysis with a more conservative intra-cluster correlation co-efficient (ICC) gave similar marginal results. Excluding one study at high risk of bias shifted the marginal pooled estimate towards no effect. There was no effect on pregnancy-related deaths (average OR 0.69, 95% CI 0.45 to 1.08; participants = 114,930; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; low quality evidence), perinatal mortality (average OR 0.98, 95% CI 0.90 to 1.07; studies = 15; Heterogeneity: Tau² = 0.01; I² = 58%; moderate quality evidence) or low birthweight (average OR 0.94, 95% CI 0.82 to 1.06; studies = five; Heterogeneity: Tau² = 0.00; I² = 5%; high quality evidence). Single interventions led to marginal improvements in the number of women who delivered in health facilities (average OR 1.08, 95% CI 1.02 to 1.15; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; high quality evidence), and in the proportion of women who had at least one ANC visit (average OR 1.68, 95% CI 1.02 to 2.79; studies = six; Heterogeneity: Tau² = 0.24; I² = 76%; moderate quality evidence). Results for ANC coverage (at least four and at least one visit) and for perinatal mortality had substantial statistical heterogeneity. Single interventions did not improve the proportion of women receiving tetanus protection (average OR 1.03, 95% CI 0.92 to 1.15; studies = 8; Heterogeneity: Tau² = 0.01; I² = 57%). No study reported onintermittent prophylactic treatment for malaria. Comparison 2: Two or more interventions versus no interventionWe found no improvements in ANC coverage of four or more visits (average OR 1.48, 95% CI 0.99 to 2.21; participants = 7840; studies = six; Heterogeneity: Tau² = 0.10; I² = 48%; low quality evidence) or pregnancy-related deaths (average OR 0.70, 95% CI 0.39 to 1.26; participants = 13,756; studies = three; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). However, combined interventions led to improvements in ANC coverage of at least one visit (average OR 1.79, 95% CI 1.47 to 2.17; studies = five; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence), perinatal mortality (average OR 0.74, 95% CI 0.57 to 0.95; studies = five; Heterogeneity: Tau² = 0.06; I² = 83%; moderate quality evidence) and low birthweight (average OR 0.61, 95% CI 0.46 to 0.80; studies = two; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). Meta-analyses for both ANC coverage four or more visits and perinatal mortality had substantial statistical heterogeneity. Combined interventions improved the proportion of women who had tetanus protection (average OR 1.48, 95% CI 1.18 to 1.87; studies = 3; Heterogeneity: Tau² = 0.01; I² = 33%). No trial in this comparison reported on intermittent prophylactic treatment for malaria. Comparison 3: Two interventions compared head to head. No trials found. Comparison 4: One intervention versus a combination of interventionsThere was no difference in ANC coverage (four or more visits and at least one visit), pregnancy-related deaths, deliveries in a health facility or perinatal mortality. No trials in this comparison reported on low birthweight orintermittent prophylactic treatment of malaria.

AUTHORS' CONCLUSIONS

Implications for practice - Single interventions may improve ANC coverage (at least one visit and four or more visits) and deliveries in health facilities. Combined interventions may improve ANC coverage (at least one visit), reduce perinatal mortality and reduce the occurrence of low birthweight. The effects of the interventions are unrelated to whether they are community or health system interventions. Implications for research - More details should be provided in reporting numbers of events, group totals and the ICCs used to adjust for cluster effects. Outcomes should be reported uniformly so that they are comparable to commonly-used population indicators. We recommend further cluster-RCTs of pregnant women and women in their reproductive years, using combinations of interventions and looking at outcomes that are important to pregnant women, such as maternal and perinatal morbidity and mortality, alongside the explanatory outcomes along the pathway of care: ANC coverage, the services provided during ANC and deliveries in health facilities.

Giving women their own case notes to carry during pregnancy

BACKGROUND

In many countries women are given their own case notes to carry during pregnancy to increase their sense of control over, and satisfaction with, their care.

OBJECTIVES

To evaluate the effects of giving women their own case notes to carry during pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials of women given their own case notes to carry during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria and assessed study quality. One review author extracted data from the included studies using a standard form (checked by second review author). We assessed estimates of effect using risk ratio (RR) with 95% confidence intervals (CI). The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

Four trials were included (n = 1176 women). Overall, the quality of the evidence was graded as low to moderate mainly due to the nature of the intervention not allowing blinding. The updated search identified one cluster-randomised trial, which was included.Women carrying their own notes were more likely to feel in control (two trials, RR 1.56, 95% CI 1.18 to 2.06; 450 women; moderate quality evidence), although there is no evidence of difference in women's satisfaction (two trials, average RR 1.09, 95% CI 0.92 to 1.29); 698 women; low quality evidence). More women in the case notes group wanted to carry their own notes in a subsequent pregnancy (three trials, RR 1.79, 95% CI 1.57 to 2.03; 552 women; low quality evidence). Overall, the pooled estimate of the two trials (n = 347) that reported on the risk of notes lost or left at home was not significant (average RR 0.38, 95% CI 0.04 to 3.84). There was no evidence of difference for health-related behaviours (cigarette smoking and breastfeeding (moderate quality evidence)), analgesia needs during labour (low quality evidence), maternal depression, miscarriage, stillbirth and neonatal deaths (moderate quality evidence). More women in the case notes group had operative deliveries (one trial, RR 1.83, 95% CI 1.08 to 3.12; 212 women), and caesarean sections (one trial, average RR 1.51, 95% CI 1.10 to 2.08; 501 women; moderate quality evidence).

AUTHORS' CONCLUSIONS

The four trials are small, and not all of them reported on all outcomes. The results suggest that there are both potential benefits (increased maternal control and increased availability of antenatal records during hospital attendance) and harms (more operative deliveries). Importantly, all of the trials report that more women in the case notes group would prefer to carry their antenatal records in another pregnancy. There is insufficient evidence on health-related behaviours (smoking and breastfeeding), women's satisfaction, and clinical outcomes. It is important to emphasise that this review shows a lack of evidence of benefit rather than evidence of no benefit.