Obstetric and neonatal outcomes in women who live in an urban resettlement area of Delhi, India: A cohort study

Burden, Differentials and Causes of Stillbirths in India: A Systematic Review and Meta Analysis

India contributes the highest absolute number of stillbirths in the world. This systematic review and meta-analysis was conducted to synthesize the burden, timing and causes of stillbirths in India. Forty-nine reports from 46 studies conducted in 21 Indian states and Union Territories were included. It was found that there was no uniformity/standardization in the definition of stillbirths and in the classification system used to assign the cause. The share of antepartum stillbirths was estimated to be two-third while remaining were intrapartum stillbirths. Maternal conditions and fetal causes were found to be the leading cause of stillbirth in India. The maternal condition was assigned as the commonest cause (25%) followed by fetal (14%), placental cause (13%), congenital malformation (6%) and intrapartum complications (4%). Approximately 20% of the stillbirths were assigned as unknown or unexplained. This review demonstrates that there is a paucity of quality stillbirth data in India. Other than the state level differences in stillbirth rates, no other data is available on inequities in stillbirths in India. There is an urgent need for strengthening availability and quality of stillbirth data in India on both stillbirth rates as well as the causes. There is a need to conduct additional research to know the timing of the stillbirths, causes of death and actual burden. India needs to strengthen stillbirth audits along with registry to find out the modifiable factors and delays for making country specific preventive strategies. The policy makers, academic community and researchers need to work together to ensure accelerated and equitable reduction in stillbirths in India.

Hospital Variation in Cesarean Delivery: A Multilevel Analysis

OBJECTIVES

To assess the issue of hospital variations in Colombia and to contribute to the methodology on health care variations by using a model that clusters the variance between hospitals while accounting for individual-level reimbursement rates and objective health-status variables.

METHODS

We used data on all births (N = 11,954) taking place in a contributory-regimen insurer network in Colombia during 2007. A multilevel logistic regression model was used to account for the share of unexplained variance between hospitals. In addition, an alternative variance decomposition specification was further carried out to measure the proportion of such unexplained variance due to the region effect.

RESULTS

Hospitals account for 20% of the variation in performing cesarean sections, whereas region explains only one-third of such variance. Variables accounting for preferences on the demand side as well as reimbursement rates are found to predict the probability of performing cesarean sections.

CONCLUSIONS

Hospital variations explain large variances within a single-payer's network. Because this insurer company is highly regarded in terms of performance and finance, these results might provide a lower bound for the scale of hospital variation in the Colombian health care market. Such lower bound provides guidance on the relevance of this issue for Colombia. Some factors such as demand-side preferences and physician reimbursement rates increase variations in health care even within a single-payer network. This is a source of inefficiencies, threatening the quality of health care and financial sustainability. The proposed methodology should be considered in further research on health care variations.

Unattended Home Labor until Complete Cervical Dilatation Ending with Hospital Delivery: Analysis of 238 Pregnancies

Objectives. Hospital fear and avoidance of the routine hospital obstetrical interventions cause some women with low-risk pregnancies to spend most of the active labor period at home, and subsequently they present to the hospital for delivery. Our aim was to analyze the maternal and neonatal outcomes of pregnancies with a planned hospital birth, yet spending the first stage of labor at home without a health provider and completing the delivery in the hospital setting. Methods. We retrospectively compared 238 pregnancies having home labor plus hospital delivery (study group) with 476 pregnancies that had spent the whole labor in the hospital setting, considering various maternal and neonatal outcomes. Results. Cesarean and episiotomy rates were lower (P < 0.0001 and P < 0.001, resp.), but neonatal intensive care unit admissions of the infants were more prevalent (P < 0.01) in the study group. Other maternal and neonatal outcomes including neonatal mortality were comparable. Conclusion. Although our preliminary data generally do support the safety of home active labor plus hospital delivery for low-risk pregnancies, the clinical implications of current data warrant further prospective trials.

Risk factors for perinatal deaths in Pakistan

AIM

The aim of this study was to identify the risk factors for perinatal deaths in Pakistan, where perinatal mortality is still very high.

MATERIALS AND METHODS

This prospective cohort study was conducted in Sindh Government Lyari General Hospital, Karachi from 1 May 2006 to 30 April 2008. During this period, all perinatal deaths and each live infant delivered following every perinatal death (which were taken as controls) were enrolled. Demographic information, birthweight, booking status, associated obstetric risk factors, stillbirth or neonatal death and the cause of death were recorded. Univariate logistic regression was used to determine the effect of categorized weight, booking status, sex and the obstetric risk factors on perinatal death.

RESULTS

A total of 1103 deliveries were conducted during this period with 119 perinatal deaths. Stillbirths constituted 68.9% while there were early neonatal deaths in 31.1% cases. Booking status, gestational age, weight of fetus and the presence of obstetric risk factors were found to have significant (P-value < 0.05) association with perinatal deaths. Among the obstetric risk factors, abruptio placentae was the commonest (13.4%) and the commonest cause of death was identified as birth asphyxia (44.5%). There was a strong association between birthweight and perinatal death.

CONCLUSIONS

The high perinatal death rate in this study is comparable to other hospital-based studies and indicates the poor health status, inadequate prenatal and intranatal care and lack of services in our setup. In order to achieve the Millennium Development Goals-4, much work is needed to improve the quality of care, to identify high-risk cases and to carry out their proper management.

Impact Factors of Korean Women's Cesarean Section according to Ecological Approach

PURPOSE

This study examined the impact factors of cesarean section based on the ecological approach in Korea.

METHODS

Population-based data (Korea Institute for Health and Social Affairs) were used from 2,849 delivery cases during 2003~2009. Data were analyzed using geographic statistics with STATA 10.0 and hierarchical logistic regression with SPSS/WIN 12.0.

RESULTS

The range of cesarean section rate was 28.8~44.7% with geographic distribution. The proportion of mother's problem was increasing in choice of cesarean section. According to the ecological model, age of mother (OR=1.08), time of birth (OR=0.79), delivery in hospital (OR=1.83), delivery in clinic (OR=1.46), and education of mother (OR=2.61) had significant impact on cesarean section.

CONCLUSION

This study contributes to provide the impact factors of the high cesarean rate in Korea ecologically. Policy maker and health care provider can consider these results to reduce cesarean section rate.

Non-uptake of facility-based maternity services in an inner-city community in Lagos, Nigeria: an observational study

Scaling-up of skilled attendants and facility-based services is necessary for improving maternal and child care in developing countries but their effectiveness is crucially influenced by the uptake of such services. This study set out to establish the pattern and uptake of maternity services and associated factors against the backdrop of rapid urbanization in Nigeria. A cross-sectional study of socio-demographic and obstetric characteristics of mothers attending the Bacille Calmette-Guérin (BCG) immunization clinics in inner-city Lagos was conducted from July 2005 to December 2007, and their association with non-hospital delivery and use of unskilled attendants was determined by multiple logistic regression analyses. Of the 6465 participants, over half (51.4%) delivered outside hospital facilities and 81.8% of this group had no skilled attendants at delivery. Non-hospital delivery or the presence of unskilled attendants at delivery was associated with teenage mothers, Muslim religion, low or middle social class and use of herbal drugs in pregnancy. Additionally, non-hospital delivery was associated with ethnicity (Yoruba tribe), lack of tertiary education or full-time employment, accommodation with shared sanitation facilities and multiparity. The results suggest that availability of and access/proximity to hospital facilities or skilled attendants is no guarantee of uptake of maternity services. Efforts aimed at improving maternal and child health in developing countries should take cognisance of the socio-demographic and cultural underpinnings of maternal health-seeking behaviour of urban mothers beyond the provision of facility-based services or strengthening of the existing health care systems.