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Pendleton AA, Dutta R, Shukla M, Jayaram A, Gadgil A, Hembram S, Roy N, Raykar NP. What to scale first? A cross-sectional analysis of factors affecting cesarean delivery rates at first referral units in Bihar, India. Glob Health Action 2023; 16:2202465. [PMID: 37133240 PMCID: PMC10158535 DOI: 10.1080/16549716.2023.2202465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Low rates of caesarean delivery (CD) (<10%) hinder access to a lifesaving procedure for the most vulnerable populations in low-resource settings, but there is a paucity of data regarding which factors contribute most to CD rates. OBJECTIVES We aimed to determine caesarean delivery rates at Bihar's first referral units (FRUs) stratified by facility level (regional, sub-district, district). The secondary aim was to identify facility-level factors associated with caesarean delivery rates. METHODS This cross-sectional study used open-source national datasets from government FRUs in Bihar, India, from April 2018-March 2019. Multivariate Poisson regression analysed association of infrastructure and workforce factors with CD rates. RESULTS Of 546,444 deliveries conducted at 149 FRUs, 16961 were CDs, yielding a state-wide FRU CD of 3.1%. There were 67 (45%) regional hospitals, 45 (30%) sub-district hospitals, and 37 (25%) district hospitals. Sixty-one percent of FRUs qualified as having intact infrastructure, 84% had a functioning operating room, but only 7% were LaQshya (Labour Room Quality Improvement Initiative) certified. Considering workforce, 58% had an obstetrician-gynaecologist (range 0-10), 39% had an anaesthetist (range 0-5), and 35% had a provider trained in Emergency Obstetric Care (EmOC) (range 0-4) through a task-sharing initiative. The majority of regional hospitals lack the essential workforce and infrastructure to perform CDs. Multivariate regression including all FRUs performing deliveries demonstrated that presence of a functioning operating room (IRR = 21.0, 95%CI 7.9-55.8, p < 0.001) and the number of obstetrician-gynaecologists (IRR = 1.3, 95%CI 1.1-1.4, p = 0.001) and EmOCs (IRR = 1.6, 95%CI 1.3-1.9, p < 0.001) were associated with facility-level CD rates. CONCLUSION Only 3.1% of the institutional childbirths in Bihar's FRUs were by CD. The presence of a functional operating room, obstetrician, and task-sharing provider (EmOC) was strongly associated with CD. These factors may represent initial investment priorities for scaling up CD rates in Bihar.
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Affiliation(s)
- Anna Alaska Pendleton
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital Boston, Boston, MA, USA
| | - Rohini Dutta
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | | | - Anusha Jayaram
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Anita Gadgil
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Sasmita Hembram
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Nobhojit Roy
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
- Department of Public Health Systems, Karolinska Institute, Stockholm, Sweden
| | - Nakul P Raykar
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Trauma, Emergency Surgery, Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Bakker W, van Dorp E, Kazembe M, Nkotola A, van Roosmalen J, van den Akker T. Management of prolonged first stage of labour in a low-resource setting: lessons learnt from rural Malawi. BMC Pregnancy Childbirth 2021; 21:398. [PMID: 34022847 PMCID: PMC8141136 DOI: 10.1186/s12884-021-03856-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
Background Caesarean sections without medical indication cause substantial maternal and perinatal ill-health, particularly in low-income countries where surgery is often less safe. In presence of adequate labour monitoring and by appropriate use of evidence-based interventions for prolonged first stage of labour, unnecessary caesarean sections can be avoided. We aim to describe the incidence of prolonged first stage of labour and the use of amniotomy and augmentation with oxytocin in a low-resource setting in Malawi. Methods Retrospective analysis of medical records and partographs of all women who gave birth in 2015 and 2016 in a rural mission hospital in Malawi. Primary outcomes were incidence of prolonged first stage of labour based on partograph tracings, caesarean section indications and utilization of amniotomy and oxytocin augmentation. Results Out of 3246 women who gave birth in the study period, 178 (5.2%) crossed the action line in the first stage of labour, of whom 21 (11.8%) received oxytocin to augment labour. In total, 645 women gave birth by caesarean section, of whom 241 (37.4%) with an indication ‘prolonged first stage of labour’. Only 113 (46.9%) of them crossed the action line and in 71/241 (29.5%) membranes were still intact at the start of caesarean section. Excluding the 60 women with prior caesarean sections, 14/181 (7.7%) received oxytocin prior to caesarean section for augmentation of labour. Conclusion The diagnosis prolonged first stage of labour was often made without being evident from labour tracings and two basic obstetric interventions to prevent caesarean section, amniotomy and labour augmentation with oxytocin, were underused. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03856-9.
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Affiliation(s)
- Wouter Bakker
- Clinical and Nursing Department, St. Luke's Hospital, Malosa, Malawi. .,Athena Institute, Faculty of Science, VU University Amsterdam, Amsterdam, The Netherlands.
| | - Elisabeth van Dorp
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Misheck Kazembe
- Clinical and Nursing Department, St. Luke's Hospital, Malosa, Malawi
| | - Alfred Nkotola
- Clinical and Nursing Department, St. Luke's Hospital, Malosa, Malawi
| | - Jos van Roosmalen
- Athena Institute, Faculty of Science, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas van den Akker
- Athena Institute, Faculty of Science, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynecology, Leiden University Medical Centre, Leiden, The Netherlands
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Lawrence ER, Appiah-Kubi A, Konney TO, Bell SG, Tawiah A, Compton SD. Preferences and perspectives on vaginal breech delivery in Ghana. Int J Gynaecol Obstet 2020; 153:307-314. [PMID: 33188705 DOI: 10.1002/ijgo.13478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/08/2020] [Accepted: 11/11/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate obstetrician/gynecologist and midwife perspectives and experiences with vaginal breech deliveries in Ghana. METHODS Respondents completed a survey on their experiences, training, comfort levels, and decision making about vaginal breech deliveries. Comparisons were made across obstetricians/gynecologists and midwives. Multiple logistic regression explored predictors of comfort performing vaginal breech deliveries. RESULTS Respondents comprised 93 (36.5%) obstetricians/gynecologists and 162 (63.5%) midwives. Most believed that some breech fetuses should be delivered vaginally, with higher agreement from obstetricians/gynecologists than from midwives (n = 86, 97.7% versus n = 207, 80.8%, P = 0.001). Midwives were more likely to strongly agree that training was adequate for obstetricians/gynecologists (n = 65, 55.6% versus n = 8, 9.8%, P < 0.001) and midwives (n = 60, 49.6% versus n = 6, 7.4%, P < 0.001). Most (n = 192, 94%) respondents wanted more experience and/or training. Despite most providers performing only one ot five breech vaginal deliveries yearly, 77.4% (n = 199) were comfortable performing them and 79.5% (n = 202) were comfortable supervising them. Significant predictors of comfort performing vaginal breech delivery were perceived adequacy of training (odds ratio 8.74, 95% CI 3.39-22.52) and belief that vaginal breech deliveries should be performed (odds ratio 4.28, 95% CI 1.33-13.72). CONCLUSION Respondents were more likely to feel comfortable performing breech vaginal deliveries if they felt that their training was adequate. Vaginal breech deliveries can only be offered as safe alternatives to cesarean delivery if training and experience are maintained in low-resource settings.
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Affiliation(s)
- Emma R Lawrence
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Adu Appiah-Kubi
- School of Medicine Department of Obstetrics and Gynecology, University of Health and Allied Sciences, Ho, Ghana
| | - Thomas O Konney
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Sarah G Bell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Augustine Tawiah
- Department of Obstetrics and Gynecology, Gynecologic Oncology Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Sarah D Compton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Wasserman I, Peters AW, Roa L, Amanullah F, Samad L. Breaking Specialty Silos: Improving Global Child Health Through Essential Surgical Care. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:183-189. [PMID: 32606090 PMCID: PMC7326524 DOI: 10.9745/ghsp-d-20-00009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/19/2020] [Indexed: 01/17/2023]
Abstract
Children’s health care providers and children’s surgery providers can partner to improve children’s health by developing the surgical workforce, focusing on “best buy” surgeries, integrating children’s surgery into national plans, streamlining data collection and research, and leveraging financing.
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Affiliation(s)
- Isaac Wasserman
- Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Alexander W Peters
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Lina Roa
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Canada
| | | | - Lubna Samad
- Center for Essential Surgical and Acute Care, Indus Health Network, Karachi, Pakistan
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