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Minani P, Ross A. Strengthening caesarean birth: Sub-Saharan Africa health system evaluation: Scoping review. Afr J Prim Health Care Fam Med 2024; 16:e1-e11. [PMID: 38708736 PMCID: PMC11079335 DOI: 10.4102/phcfm.v16i1.4128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Promoting safe caesarean birth (CB) is a challenge in sub-Saharan Africa (SSA) where maternal and neonatal mortality rates are high due to inadequate maternal health services. Although the CB rate in SSA is lower than the World Health Organization (WHO) recommendation, it is often associated with high maternal and neonatal mortality. AIM The aim of this scoping review was to report on the extent to which SSA health systems deliver safe CB. METHODS A systematic search across various databases identified 53 relevant studies, comprising 30 quantitative, 10 qualitative and 16 mixed methods studies. RESULTS These studies focused on clinical protocols, training, availability, accreditation, staff credentialing, hospital supervision, support infrastructure, risk factors, surgical interventions and complications related to maternal mortality and stillbirth. CB rates in SSA varied significantly, ranging from less than 1% to a high rate of 29.7%. Both very low as well as high rates contributed to significant maternal and neonatal morbidity. Factors influencing maternal and perinatal mortality include poor referral systems, inadequate healthcare facilities, poor quality of CBs, inequalities in access to maternity care and affordable CB intervention. CONCLUSION The inadequate distribution of healthcare facilities, and limited access to emergency obstetric care impacted the quality of CBs. Early access to quality maternity services with skilled providers is recommended to improve CB safety.Contributions: This scoping review contributes to the body of knowledge motivating for the prioritization of maternal service across SSA.
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Affiliation(s)
- Patrick Minani
- Department of Public Health Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban.
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Gantt DM, Misselwitz B, Boos V, Reitter A. Errors in the classification of pregnant women according to Robson ten-group classification system. Eur J Obstet Gynecol Reprod Biol 2024; 295:53-57. [PMID: 38335585 DOI: 10.1016/j.ejogrb.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/25/2024] [Accepted: 02/04/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVES The Robson Ten-Group Classification System (TGCS) is widely used as a classification system for perinatal analyses such as Caesarean section (CS) rates. In Germany, standardised data sets on deliveries are classified by quality assurance institutions using the TGCS. This observational study aims to evaluate potential errors in the TCGS classification of deliveries. STUDY DESIGN Manual TGCS classification of all 1370 deliveries in an obstetric unit in 2018 and comparison with semi-automatic TGCS classifications of the quality assurance institution. RESULTS In the manual classification, 259 out of 1370 births (18.9 %) were assigned to a different Robson group than in the semi-automatic classification. The proportions of births by Robson group were significantly different in TGCS group 1 (32.2 % vs. 37.6 %, p = 0.0034) and group 2 (18.4 % vs. 14.4 %, p = 0.0053). Concordance between manual and semi-automatic classifications ranged from 59.5 % in group 2 to 100.0 % in groups 6, 7, 8, and 9. The most frequent mismatches were for the parameters "onset of labour" in 184 cases (13.4 %), "parity" in 42 cases (3.1 %) and "previous uterine scars" in 23 cases (1.7 %). In the manual classification, there were significant differences in the CS rate in group 1 (7.9 % vs. 2.5 %, p < 0.0001), group 2 (30.2 % vs. 48.2 %, p < 0.0001), and group 4 (14.1 % vs. 37.4 %, p = 0.0004), compared to the semi-automatic classification. CONCLUSIONS Due to incorrect data entry and unclear definitions of criteria, quality assurance data in obstetric databases may contain a relevant proportion of errors, which could influence statistics with TGCS in context of CS rates in international comparisons.
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Affiliation(s)
| | - Björn Misselwitz
- Federal State Consortium of Quality Assurance Hesse (Landesarbeitsgemeinschaft Qualitätssicherung Hessen, LAGQH), Frankfurter Str. 10, 65760 Eschborn, Germany.
| | - Vinzenz Boos
- Newborn Research, Department of Neonatology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland.
| | - Anke Reitter
- Goethe-University Frankfurt, Theodor-Stern-Kai, 60596 Frankfurt am Main, Germany; Department of Obstetrics, Hospital Zollikerberg, Trichtenhauserstrasse 20, 8125 Zollikerberg, Switzerland.
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Shtainmetz N, Tesler R, Sharon C, Korn L. Optimizing caesarean section use and feasibility of implementing the Robson classification system: Perspectives of healthcare providers and policymakers. SAGE Open Med 2024; 12:20503121241237447. [PMID: 38533202 PMCID: PMC10964469 DOI: 10.1177/20503121241237447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/15/2024] [Indexed: 03/28/2024] Open
Abstract
Introduction and Objective In recent decades, caesarean section rates have increased dramatically worldwide and the reasons for this trend are not fully understood. This continuing trend has raised public health concerns regarding higher maternal and perinatal risks, high costs, healthcare efficiency, and inequality of services. The current study aimed to explore the perspectives and insights of healthcare providers and policymakers in the Israeli health system regarding the factors that drive caesarean section rates and the readiness and feasibility of implementing the Robson Ten Group Classification System for the first time. Methods Semi-structured interviews were conducted (n = 12) with purposefully selected healthcare providers and policymakers in Israel. Data was analysed inductively using a thematic analysis approach. Results The findings reflected the "changing landscape" in childbirth practices and attitudes that contributes to the rising caesarean section rate, including childbirth at older ages, birth planning, and a transition toward a more collaborative decision-making approach to childbirth. The participants emphasized the lack of a standardized classification or consistent data monitoring of caesarean section in the Israeli health system. Additionally, enablers to implement the Robson Ten Group Classification System in Israel (ease of use, data collection and recording, and the allocation of resources and personnel), as well as barriers (concerns over workload, limited resources, budget implications, and technological complexity), were found. Conclusions This study revealed the multifaceted factors shaping caesarean section rates within Israel and underscored the perceived need for evidence-based monitoring and informed decision-making in healthcare practices. Our findings support the conclusion that empirical evidence and clear data are crucial for effective caesarean section use and are currently lacking in Israeli hospitals. Thus, it is recommended to adopt a globally standardized, accepted, and effective tool-the Robson Ten Group Classification System-to accommodate the "changing landscape" in alignment with evolving medical and societal dynamics, which consequently will assist in optimizing caesarean section use.
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Affiliation(s)
- Noa Shtainmetz
- Department of Health Systems Management, School of Health Sciences, Ariel University, Ariel, Israel
| | - Riki Tesler
- Department of Health Systems Management, School of Health Sciences, Ariel University, Ariel, Israel
| | - Cochava Sharon
- The Academic College of Law and Science, Hod Hasharon, Israel
| | - Liat Korn
- Department of Health Systems Management, School of Health Sciences, Ariel University, Ariel, Israel
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Nantume S, Baluku EM, Kwesiga D, Waiswa P. Factors Associated with High Rates of Caesarean Deliveries: A Cross Sectional Study Classifying Deliveries According to Robson in Mengo Hospital Kampala. Risk Manag Healthc Policy 2023; 16:2339-2356. [PMID: 37965117 PMCID: PMC10641024 DOI: 10.2147/rmhp.s422705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/01/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction The number of caesarean section (CS) continues to rise worldwide. CS can improve outcomes in infants and mothers. However, if used improperly, the potential harm can outweigh the potential benefits. Aim The study was to determine the factors associated with high cesarean section rates at Mengo Hospital. Methods This cross-sectional study used a mixed-method approach that included a retrospective review of 1276 casebooks using the Robson Ten Group Classification System (RTGCS) for births that occurred at Mengo Hospital in December 2018, January, and February 2019. Questionnaire was used for data collection from 200 mothers on second day after birth from 24th May to 19th July 2019. Eight key informants were interviewed within the same period. Quantitative data were analyzed using STATA V.14, thematic analysis for qualitative data. Univariate, bivariate, and multivariate analyses were performed to determine the association between predisposing factors and outcome variables using chi-square and modified Poisson. Results Caesarean section rate (CSR) from casebooks was 49% and 64% from the primary data. Group 5(Previous CS, single cephalic, >37 weeks) had (35.4%) to the total number of cesarean deliveries, followed by Group 1 (Nulliparous, single cesarean deliveries, >37 weeks in spontaneous labour), with 18.4%. Group 3 (ultiparous (excluding previous CS), single cephalic, >37 weeks of spontaneous labor) with (13.7%). The common indications from casebooks were a previous scar (32%), obstructed labor (18%), and previous scar (97.6%). Presence of an obstetric indication, influence of husband, friends, relatives, and mother's desire for a CS were closely associated with caesarean delivery. Mothers said that occurrence of CS was due to health workers reducing the stress of monitoring labour and financial benefits from CS deliveries by the hospital. Conclusion Repeat CS made the highest CSR contribution; therefore, strategies to reduce the frequency of the procedure should include avoiding medically unnecessary primary CS and encouraging vaginal birth after previous CS where applicable.
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Affiliation(s)
- Susan Nantume
- College of Health Science, Makerere University, Kampala, Uganda
| | - Eric Murungi Baluku
- Department of Nursing, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Doris Kwesiga
- College of Health Science, Makerere University, Kampala, Uganda
| | - Peter Waiswa
- College of Health Science, Makerere University, Kampala, Uganda
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Albarqouni L, Abukmail E, MohammedAli M, Elejla S, Abuelazm M, Shaikhkhalil H, Pathirana T, Palagama S, Effa E, Ochodo E, Rugengamanzi E, AlSabaa Y, Ingabire A, Riwa F, Goraya B, Bakhit M, Clark J, Arab-Zozani M, Alves da Silva S, Pramesh CS, Vanderpuye V, Lang E, Korenstein D, Born K, Tabiri S, Ademuyiwa A, Nabhan A, Moynihan R. Low-Value Surgical Procedures in Low- and Middle-Income Countries: A Systematic Scoping Review. JAMA Netw Open 2023; 6:e2342215. [PMID: 37934494 PMCID: PMC10630901 DOI: 10.1001/jamanetworkopen.2023.42215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/22/2023] [Indexed: 11/08/2023] Open
Abstract
Importance Overuse of surgical procedures is increasing around the world and harms both individuals and health care systems by using resources that could otherwise be allocated to addressing the underuse of effective health care interventions. In low- and middle-income countries (LMICs), there is some limited country-specific evidence showing that overuse of surgical procedures is increasing, at least for certain procedures. Objectives To assess factors associated with, extent and consequences of, and potential solutions for low-value surgical procedures in LMICs. Evidence Review We searched 4 electronic databases (PubMed, Embase, PsycINFO, and Global Index Medicus) for studies published from database inception until April 27, 2022, with no restrictions on date or language. A combination of MeSH terms and free-text words about the overuse of surgical procedures was used. Studies examining the problem of overuse of surgical procedures in LMICs were included and categorized by major focus: the extent of overuse, associated factors, consequences, and solutions. Findings Of 4276 unique records identified, 133 studies across 63 countries were included, reporting on more than 9.1 million surgical procedures (median per study, 894 [IQR, 97-4259]) and with more than 11.4 million participants (median per study, 989 [IQR, 257-6857]). Fourteen studies (10.5%) were multinational. Of the 119 studies (89.5%) originating from single countries, 69 (58.0%) were from upper-middle-income countries and 30 (25.2%) were from East Asia and the Pacific. Of the 42 studies (31.6%) reporting extent of overuse of surgical procedures, most (36 [85.7%]) reported on unnecessary cesarean delivery, with estimated rates in LMICs ranging from 12% to 81%. Evidence on other surgical procedures was limited and included abdominal and percutaneous cardiovascular surgical procedures. Consequences of low-value surgical procedures included harms and costs, such as an estimated US $3.29 billion annual cost of unnecessary cesarean deliveries in China. Associated factors included private financing, and solutions included social media campaigns and multifaceted interventions such as audits, feedback, and reminders. Conclusions and Relevance This systematic review found growing evidence of overuse of surgical procedures in LMICs, which may generate significant harm and waste of limited resources; the majority of studies reporting overuse were about unnecessary cesarean delivery. Therefore, a better understanding of the problems in other surgical procedures and a robust evaluation of solutions are needed.
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Affiliation(s)
- Loai Albarqouni
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Eman Abukmail
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Majdeddin MohammedAli
- Medicine & Health Sciences Faculty, Department of Medicine, An-Najah National University, Nablus, Palestine
| | - Sewar Elejla
- Faculty of Medicine, Islamic University of Gaza, Gaza Strip, Palestine
| | | | | | - Thanya Pathirana
- School of Medicine and Dentistry, Griffith University, Sunshine Coast, Australia
| | - Sujeewa Palagama
- School of Medicine and Dentistry, Griffith University, Sunshine Coast, Australia
| | - Emmanuel Effa
- Department of Internal Medicine, Faculty of Clinical Sciences, College of Medical Sciences, University of Calabar, Calabar, Nigeria
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Kismu City, Kenya
- Centre for Evidence-Based Health Care, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Eulade Rugengamanzi
- Department of Clinical Oncology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Yousef AlSabaa
- Faculty of Medicine, Al-Azhar University of Gaza, Gaza Strip, Palestine
| | - Ale Ingabire
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Francis Riwa
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Burhan Goraya
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | | | - C. S. Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Verna Vanderpuye
- National Centre for Radiotherapy, Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - Eddy Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah Korenstein
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karen Born
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen Tabiri
- Department of Surgery, University for Development Studies–School of Medicine and Tamale Teaching Hospital, Tamale, Ghana
| | - Adesoji Ademuyiwa
- Paediatric Surgery Unit, Department of Surgery, Faculty of Clinical Sciences, College of Medicine of the University of Lagos and Lagos University Teaching Hospital, Idi Araba, Lagos
| | - Ashraf Nabhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ray Moynihan
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
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Yussuph ZH, Alwy Al-beity FM. Shared decision making on mode of delivery following a prior cesarean delivery in Dar es Salaam, Tanzania. PLoS One 2023; 18:e0291809. [PMID: 37883339 PMCID: PMC10602314 DOI: 10.1371/journal.pone.0291809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 09/06/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Shared decision-making between clinicians and pregnant women with prior cesarean on the subsequent mode of delivery improves trial of labor rates, and reduces the number of repeat cesarean sections and their related complications. However, this practice is insufficient worldwide and the factors influencing it are still unknown. The study aimed at determining the proportion of pregnant women involved in shared decision-making and its associated factors in Dar es Salaam. METHODS A cross-sectional analytical study among 350 pregnant women with one prior cesarean section. Data was collected using a structured questionnaire and SPSS 23 was used for analysis. A score of 80 or higher on the nine-item Shared Decision-Making Questionnaire (SDM-Q9) was used to calculate the proportion of women, and the associated factors were obtained using a logistic regression model. P value of < 0.05 was considered significant. RESULTS The proportion of pregnant women involved in shared decision making was 38%. Factors that were significantly associated with sharing decision making were; having low level of education (AOR 0.55 95% CI 0.33-0.91), being married/having partner (AOR 2.58 95% CI 1.43-4.63), having a companion who had active participation (AOR 3.31 95% CI 1.03-10.6) and being familiar with the clinician (AOR 5.01 95% CI 1.30-19.2). CONCLUSION To promote practice of shared decision making in our setting, encouragement of socially vulnerable pregnant women's participation in decision-making by health care professionals, encouragement of companion participation during antenatal care and promotion of personal continuity of care to improve familiarity to clinicians are needed.
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Affiliation(s)
- Zainab Hassan Yussuph
- Department of Obstetrics and Gynecology, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Fadhlun M. Alwy Al-beity
- Department of Obstetrics and Gynecology, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
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Boas JT, Mola GD, Elijah A. A study comparing the
WHO
C‐Model caesarean section rates and observed caesarean section rates at Port Moresby General Hospital, Papua New Guinea. Aust N Z J Obstet Gynaecol 2022. [DOI: 10.1111/ajo.13621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/12/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Jameson T. Boas
- Department of Obstetrics and Gynaecology Port Moresby General Hospital Port Moresby Papua‐New Guinea
| | - Glen D.L. Mola
- Department of Obstetrics and GynaecologySchool of Medicine and Health Sciences University of Papua‐New Guinea Port Moresby Papua‐New Guinea
| | - Arthur Elijah
- Department of Obstetrics and Gynaecology Port Moresby General Hospital Port Moresby Papua‐New Guinea
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Prediction of Scar Myometrium Thickness and Previous Cesarean Scar Defect Using the Three-Dimensional Vaginal Ultrasound. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:3584572. [PMID: 36262982 PMCID: PMC9556220 DOI: 10.1155/2022/3584572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/06/2022] [Accepted: 07/20/2022] [Indexed: 01/26/2023]
Abstract
This research aimed to explore the related factors of scar myometrial thickness and scar diverticulum formation and then predict the occurrence of uterine diverticula. 140 patients with cesarean section were selected as the research objects. According to the three-dimensional (3D) vaginal ultrasound echo and the diagnostic criteria of uterine diverticulum, the research objects were divided into a diverticulum group and a control group, with 70 cases in each group. Data such as age, number of cesarean sections, endometrial thickness, uterine position, and diverticulum size was collected, and their relationship with uterine diverticulum was compared and analyzed. The results showed that there were significant differences in menstrual days, cesarean section times, and uterine position between the two groups (P < 0.05). The height (9.02 ± 2.97), width (14.02 ± 3.08), and depth (5.14 ± 1.23) of the posterior uterine diverticula in the scar diverticulum group were all greater than the anterior uterine height (6.69 ± 1.36), the width (10.69 ± 2.15), and the depth (3.86 ± 0.69), respectively. The residual myometrium thickness in posterior position of the uterus (2.98 ± 0.75) was < anterior position of uterus (3.43 ± 0.47), and the difference was statistically significant (P < 0.05). Multivariate analysis showed that the frequency of cesarean section (1 time, 2 times), uterine position, and abnormal menstruation were independent risk factors in the scar diverticulum group (P < 0.05). In conclusion, menstrual abnormalities, the number of cesarean sections (1 time or twice), and the position of the uterus are independent risk factors for the formation of uterine scar diverticula. The deeper the diverticula, the more likely to have menstrual abnormalities, the more prone to diverticulum in patients with posterior uterus, and the deeper the diverticula in patients with 2 dissections.
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Colomar M, Colistro V, Sosa C, de Francisco LA, Betrán AP, Serruya S, De Mucio B. Cesarean section in Uruguay from 2008 to 2018: country analysis based on the Robson classification. An observational study. BMC Pregnancy Childbirth 2022; 22:471. [PMID: 35672663 PMCID: PMC9175367 DOI: 10.1186/s12884-022-04792-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 05/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background The use of caesarean section has steadily increased, with Latin America being the region with the highest rates. Multiple factors account for that increase and the Robson classification is appropriate to compare determinants at the clinical level for caesarean section rates over time. The purpose of this study is to describe the evolution of caesarean section rates by Robson groups in Uruguay from 2008 to 2018 using a country level database. Methods We included the records of all women giving birth in Uruguay (pregnancies ≥22 weeks and weights ≥500 g) with valid data in the mode of childbirth recorded in the Perinatal Information System database between 2008 and 2018. Caesarean section rates were calculated by Robson groups for each of the years included, disaggregated by care sector (public/private) and by geographical area (Capital City/Non-Capital), with time trends and their significance analyzed using linear regression models. Results Of the total 485,263 births included in this research, the overall caesarean section rate was 43,1%. In 2018, among the groups at lower risk of caesarean section (1 to 4), the highest rates were seen in women in group 2B (98,8%), followed by those in group 4B (97,9%). A significant increase in the number of caesarean sections was seen in groups 2B (97,9 to 98,8%), 3 (8,36 to 11,1%) and 4 (A (22,7 to 26,9%) and B (95,4 to 97,9%) Significant growth was also observed in groups 5 (74,3 to 78,1%), 8 (90,6 to 95,5%), and 10 (39,1 to 46,7%). The private sector had higher rates of caesarean section for all groups throughout the period, except for women in group 9. The private sector in Montevideo presented the highest rates in the groups with the lowest risk of caesarean section (1, 2A, 3 and 4A), followed by the private sector outside of the capital. Conclusion Uruguay is no exception to the increasing caesarean section trend, even in groups of women who have lower risk of requiring caesarean section. The implementation of interventions aimed at reducing caesarean section in the groups with lower obstetric risk in Uruguay is warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04792-y.
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Affiliation(s)
- Mercedes Colomar
- Montevideo Clinical and Epidemiological Research Unit, Montevideo, Uruguay. .,Latin American Center for Perinatology, Women and Reproductive Health (CLAP/WR), PAHO/WHO, Montevideo, Uruguay.
| | - Valentina Colistro
- Department of Quantitative Methods, School of Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - Claudio Sosa
- Department of Obstetrics and Gynecology, Pereira Rossell Hospital, School of Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - Luis Andres de Francisco
- Family, Health Promotion and Life Course, Pan American Health Organization, World Health Organization, Washington, United States
| | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Suzanne Serruya
- Latin American Center for Perinatology, Women and Reproductive Health (CLAP/WR), PAHO/WHO, Montevideo, Uruguay
| | - Bremen De Mucio
- Latin American Center for Perinatology, Women and Reproductive Health (CLAP/WR), PAHO/WHO, Montevideo, Uruguay
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Ghosh R, Santos N, Butrick E, Wanyoro A, Waiswa P, Kim E, Walker D. Stillbirth, neonatal and maternal mortality among caesarean births in Kenya and Uganda: a register-based prospective cohort study. BMJ Open 2022; 12:e055904. [PMID: 35387820 PMCID: PMC8987792 DOI: 10.1136/bmjopen-2021-055904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To investigate the interaction of risks for adverse maternal and perinatal outcomes (stillbirth, predischarge neonatal and maternal mortality) among caesarean section (CS) compared with vaginal deliveries (VD). DESIGN Prospective cohort study. SETTING 10 CS-capable facilities in Busoga Region, East-Central Uganda and Migori County, Kenya. PARTICIPANTS Individual birth data were extracted from maternity registers between October 2016 and April 2019. There were a total of 77 242 livebirths and 3734 stillbirths. Overall, 24% of deliveries were by CS with a range of 9%-49% across facilities. PRIMARY OUTCOME MEASURES Stillbirth, predischarge neonatal mortality and maternal mortality. RESULTS The adjusted ORs for stillbirth, predischarge neonatal mortality and maternal mortality after a CS were 1.3 (95% CI 1.1 to 1.6), 1.9 (95% CI 1.6 to 2.2) and 3.3 (95% CI 2.2 to 4.9), respectively, compared with a VD. The association between maternal mortality and CS was 3.9 (95% CI 2.8 to 5.5) when the delivery was a live birth and 1.7 (95% CI 1.0 to 3.0) when it was a stillbirth. Post hoc analyses showed that mothers who received a CS had a lower risk of stillbirth if they were documented as a referral. CONCLUSION In this context, CS births were at higher risk for worse outcomes compared with VD. Better understanding of CS use and associated adverse outcomes within the mother-baby dyad is necessary to identify opportunities to improve quality of intrapartum care. TRIAL REGISTRATION NUMBER NCT03112018.
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Affiliation(s)
- Rakesh Ghosh
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Butrick
- University of California San Francisco, San Francisco, California, USA
| | | | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Eliana Kim
- University of California San Francisco, San Francisco, California, USA
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
- University of California San Francisco Department of Obstetrics Gynecology and Reproductive Sciences, San Francisco, California, USA
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11
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Okonta PI, Fajola A, Umejiego C. An Analysis of Caesarean Sections in a Community Cottage Hospital in Nigeria's Niger Delta Using The Robson Classification. Niger Med J 2022; 63:91-97. [PMID: 38803701 PMCID: PMC11128161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Background The Robson ten group classification is recommended for classifying and comparing Caesarean Sections. This study aimed to review and classify all CS done at Obio Cottage hospital in 2018 using the Robson classification and to also identify areas of possible intervetions in reducing the CS rates. Methodology A retrospective review of all caesarean sections at Obio Cottage hospital from January to December 2018 using the Robson classification. Results The CS rate was 32.4%. Three groups - Groups 1 (27.% ), 2 (11.2%) and 5 (30.1%) contributed 68.5% to the overall CS rate. Group 8 had the least contribution to CS with 3.4%. Women in Robson group 3 had the lowest group CS rate of 6.86%, while the group CS rate for group 1, and 5.1 were 26.34% and 70.49% respectively. Conclusion The CS rate of 32.4% is comparatively high. This analysis of the CS using the Robson classification system has revealed areas for further scrutiny and intervention. There is need to review the package of care provided to women in labour and increase the number of women offered a trial of labour after a Caesarean birth.
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Affiliation(s)
- Patrick I. Okonta
- Sabbaticcal Research Advisor, SPDC, Port Harcourt, Rivers State
- Department of Obstetrics and Gynaecology, Delta State University, Abraka, Delta State
| | | | - Chidozie Umejiego
- Medical Director, Obio Cottage Hospital, Port Harcourt, Rivers State
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12
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Rukewe A, Orlam I, Akande A, Fatiregun AA. Distribution of cesarean delivery by Robson classification and predictors of postspinal anesthesia hypotension in Windhoek referral hospitals: A cross-sectional study. Niger J Clin Pract 2022; 25:178-184. [PMID: 35170444 DOI: 10.4103/njcp.njcp_573_20] [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: 11/04/2022]
Abstract
Background There are concerns that high cesarean section (CS) rates are driven by nonmedical indications and unmitigated maternal hypotension following spinal anesthesia (SA) has materno fetal effects. Aims Our objective was to investigate CS rates using Robson classification, identify patient groups for focused intervention as well as assess the incidence and predictors of maternal hypotension following SA for cesarean delivery. Subjects and Methods A cross sectional design was employed over 3 months (February-April, 2019). Data about total deliveries (vaginal and operative) were obtained from the hospital medical records. For parturients who had CS, variables which covered maternal characteristics, conduct of anesthesia, and the index pregnancy according to Robson classification system were entered into a proforma designed for the study. Results The total deliveries were 3031, of which 556 were CSs, giving a CS rate of 18.3%. Twenty one nonconsenting parturients were excluded, so 535 responded. Robson groups 5, 10, and 1 combined contributed 75% [401/535] to the overall CS. Two or more previous CS, 29.7% [159/535], was the main indication for performing CS, followed by maternal request 12.9% [69/535]. The incidence of maternal hypotension was 62.6% (293/468); the independent predictors were elective CS and having comorbidities. Conclusion We found a low CS rate and Robson groups 5, 10, and 1 were the major contributors - previous CS (≥2) and maternal request were the predominant indications for performing CS. The independent predictors of SA induced hypotension were presence of comorbidities and elective CS.
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Affiliation(s)
- A Rukewe
- Division of Anaesthesiology, Department of Surgical Sciences, School of Medicine, University of Namibia; Department of Anaesthesia, Windhoek Central & Katutura State Hospitals, Windhoek, Namibia
| | - I Orlam
- Department of Anaesthesia, Windhoek Central & Katutura State Hospitals, Windhoek, Namibia
| | - A Akande
- Department of Community Medicine, Faculty of Public Health, University College Hospital, Ibadan, Nigeria
| | - A A Fatiregun
- World Health Organization, Akure office, Akure, Ondo State, Nigeria
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13
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Agboola A, Bello O. Utilizing the Robson 10-Group Classification System as an Audit Tool in Assessing the Soaring Caesarean Section Rates in Ibadan, Nigeria. JOURNAL OF WEST AFRICAN COLLEGE OF SURGEONS 2022; 12:64-69. [PMID: 36203917 PMCID: PMC9531747 DOI: 10.4103/jwas.jwas_43_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/06/2022] [Indexed: 11/25/2022]
Abstract
Background: The caesarean section (CS) is the most common operation performed globally with increased incidence worldwide. Aim and Objectives: Using the Robson 10-Group Classification System (RTGCS), we aimed to identify women who were the main contributors to the high CS rate (CSR) over a 3-year period at a foremost tertiary health facility. Settings: This study was conducted at the Department of Obstetrics and Gynecology, University College Hospital, Ibadan, Nigeria. Materials and Methods: This study is a retrospective study of all women who delivered by CS at the University College Hospital, Ibadan, Nigeria from January 2017 to December 2019. Data were obtained using a structured proforma and women were categorized according to the RTGCS. Data were analysed using SPSS version 21. Descriptive statistics (frequency, percentage, mean) carried out were presented in tables. Results: The CSR was 46.9%. Women in Group 5 (parous women >37 weeks with previous CS and a single foetus in cephalic presentation), Group 1 (nulliparous women >37 weeks with a single foetus in cephalic presentation and spontaneous labour), and Group 10 (women <37 weeks with a single foetus in cephalic presentation) were major contributors to the CSR, with 30.9%, 17.7%, and 13.7%, respectively. Stillbirth rates were highest in Groups 10 (30.3%), 3 (24.4%), and 8 (16.8%). Apgar score <7 at the 5th minute was highest in Groups 5 (29.7%), 10 (17%), and 1 (16.6%). Conclusion: In a bid to reduce caesarean deliveries, efforts should focus on increasing the proportion of vaginal deliveries in these identified groups, especially in women with a history of one CS.
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McCall SJ, Semaan A, Altijani N, Opondo C, Abdel-Fattah M, Kabakian-Khasholian T. Trends, wealth inequalities and the role of the private sector in caesarean section in the Middle East and North Africa: A repeat cross-sectional analysis of population-based surveys. PLoS One 2021; 16:e0259791. [PMID: 34784384 PMCID: PMC8594794 DOI: 10.1371/journal.pone.0259791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/22/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To examine trends and variations of caesarean section by economic status and type of healthcare facility in Arab countries in the Middle East and North Africa (MENA). Methods Secondary data analysis of nationally representative household surveys conducted between 2008–2020 across nine Arab countries in the MENA region. The study population was women aged 15–49 years with a live birth in the two years preceding the survey. Temporal changes in the proportion of deliveries by caesarean section in each country were calculated using generalised linear models and presented as risk differences (RD) with 95% confidence intervals (95%CI). Caesarean section was disaggregated by household wealth index and type of healthcare facility. Results Use of caesarean section ranged from 57.3% (95%CI:55.6–59.1%) in Egypt to 5.7% of births (95%CI:4.9–6.6%) in Yemen. Overall, the use of caesarean section has increased across the MENA region, except in Jordan, where there was no evidence of change (RD -2.3 (95%CI: -6.0 ‒1.4)). Across most countries, caesarean section use was highest in the richest quintile compared to the poorest quintile, for example, 42.8% (95%CI:38.0–47.6%) vs. 22.6% (95%CI:19.6–25.9%) in Iraq, respectively. Proportion of caesarean section was higher in private sector facilities compared to public sector: 21.8% (95%CI:18.2–25.9%) vs. 15.7% (95%CI:13.3–18.4%) in Yemen, respectively. Conclusion Variations in caesarean section exist within and between Arab countries, and it was more commonly used amongst the richest quintiles and in private healthcare facilities. The private sector has a prominent role in observed trends. Urgent policies and interventions are required to address non-medically indicated intervention.
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Affiliation(s)
- Stephen J. McCall
- Department of Epidemiology and Population Health, Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- * E-mail: (SJM); (TKK)
| | - Aline Semaan
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Noon Altijani
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Charles Opondo
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Mohamed Abdel-Fattah
- Aberdeen Center for Women’s Health Research, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Tamar Kabakian-Khasholian
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- * E-mail: (SJM); (TKK)
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Habib M, Adegnika AA, Honkpehedji J, Klug SJ, Lobmaier S, Vogg K, Bustinduy AL, Ullrich A, Reinhard-Rupp J, Esen M, Prazeres da Costa C. The challenges for women's health in sub-Saharan Africa: Lessons learned from an integrative multistakeholder workshop in Gabon. J Glob Health 2021; 11:02002. [PMID: 34552713 PMCID: PMC8442509 DOI: 10.7189/jogh.11.02002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Marrium Habib
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich (TUM), Munich, Germany.,Center for Global Health, TUM School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Ayola Akim Adegnika
- Institute for Tropical Medicine (ITM), University Clinic Tübingen, (UKT), Tübingen, Germany.,Centre de Réchèrches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon
| | - Josiane Honkpehedji
- Centre de Réchèrches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon.,German Center for Infection Research (DZIF), Tübingen, Germany
| | - Stefanie J Klug
- Chair of Epidemiology, Department of Sport and Health Sciences, Technical University of Munich (TUM), Munich, Germany
| | - Silvia Lobmaier
- Clinic and Polyclinic for Gynecology, University Hospital, Klinikum Rechts der Isar (MRI), Technical University Munich (TUM), Munich, Germany
| | - Kathrin Vogg
- Clinic and Polyclinic for Gynecology, University Hospital, Klinikum Rechts der Isar (MRI), Technical University Munich (TUM), Munich, Germany
| | - Amaya L Bustinduy
- Department of Clinical Research, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | | | | | - Meral Esen
- Institute for Tropical Medicine (ITM), University Clinic Tübingen, (UKT), Tübingen, Germany.,Centre de Réchèrches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon.,German Center for Infection Research (DZIF), Tübingen, Germany
| | - Clarissa Prazeres da Costa
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich (TUM), Munich, Germany.,Center for Global Health, TUM School of Medicine, Technical University of Munich (TUM), Munich, Germany.,German Center for Infection Research (DZIF), Tübingen, Germany
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Mose A, Abebe H. Magnitude and associated factors of caesarean section deliveries among women who gave birth in Southwest Ethiopia: institutional-based cross-sectional study. Arch Public Health 2021; 79:158. [PMID: 34470668 PMCID: PMC8411533 DOI: 10.1186/s13690-021-00682-5] [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: 04/20/2021] [Accepted: 08/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Caesarean section is a life-saving comprehensive obstetric procedure of women and newborn performed during childbirth-related complications and should be universally accessible for all pregnant mothers globally. Appropriate use of caesarean section can reduce maternal and perinatal mortality. However, inappropriate use of caesarean section can negatively affect infant health, women health, and future pregnancies. The magnitude and factors associated with caesarean section delivery were not consistent and will vary between different hospitals of Ethiopia. Hence, this study aimed at assessing the magnitude and factors associated with caesarean section deliveries in Southwest Ethiopia. METHODS AND MATERIALS An institutional-based cross-sectional study was conducted from January 1 to February 29, 2020. A systematic random sampling technique was used to select 551 study participants. A pretested, structured, and face-to-face interview was used to collect data. Data were entered into Epi-data version 4.2.0 and exported to SPSS version 23 for analysis. Bivariate and multivariate analyses were used to identify factors associated with caesarean section deliveries. P values < 0.05 result were considered as a statistically significant association. RESULTS The magnitude of caesarean section deliveries was found to be 32.5 % (95 % CI; 28.6%-36.7 %). Mothers resided in an urban area [AOR = 2.58, (95% CI; 1.66-4.01)], multiple pregnancies [AOR = 3.15, (95% CI; 1.89-5.23), malpresentation [AOR = 3.05, (95% CI; 1.77-5.24)], and previous history of caesarean section [AOR = 3.55, (95% CI; 2.23-5.64) were factors associated with caesarean section deliveries. CONCLUSIONS Caesarean section deliveries were found high in the study area. Mothers resided in an urban area, multiple pregnancies, malpresentation, and previous history of caesarean section were factors associated with caesarean section deliveries. Therefore, counselling of mothers on the risk of giving birth through elective caesarean section without absolute and relative medical indications and giving enough time for the trial of vaginal birth after caesarean section are recommended.
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Affiliation(s)
- Ayenew Mose
- Department of Midwifery, College of Medicine and Health Science, Wolkite University, P.O.Box; 07, Wolkite, Ethiopia
| | - Haimanot Abebe
- Department of Public Health, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia
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17
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Rationale of indications for caesarean delivery and associated factors among primigravidae in Tanzania. J Taibah Univ Med Sci 2021; 16:350-358. [PMID: 34140861 PMCID: PMC8178681 DOI: 10.1016/j.jtumed.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 01/14/2021] [Accepted: 01/16/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to determine the prevalence of modes of delivery and associated maternal and newborn outcomes among singleton primigravidae in the Iringa region of Tanzania. Methods A cross-sectional, analytical hospital-based study was conducted in the Iringa region among 356 singleton primigravidae between April and August 2018. Convenience sampling and consecutive collection of data using a face-to-face interviewer-administered questionnaire was done. Results A total of 356 singleton primigravid women with a mean age of 22.0 years (range: 15–49) participated in the study. The majority of the participants (73.0%, n = 250) were in the 20–35 age group. Caesarean and vaginal delivery were performed in 41.3% (n = 147) and 58.7% (n = 209) of the cases, respectively. The maternal height and weight of the newborn were significantly associated with caesarean delivery; (p = 0.001) and (p = 0.029), respectively. After adjusting for all variables, birth asphyxia (AOR = 3.25, 95% CI: 1.867–5.646, p = 0.000) and low birth weight (AOR = 0.03, 95% CI: 0.003–0.211, p = 0.001) were associated with caesarean delivery. Conclusions The findings of our study indicated the prevalence of caesarean section to be three times more than that recommended by the World Health Organization. Pregnant women with a height of less than 150 cm should be considered for caesarean section. Therefore, it is necessary for stakeholders in the health sector to formulate guidelines for absolute indications for caesarean section.
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18
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Doraiswamy S, Billah SM, Karim F, Siraj MS, Buckingham A, Kingdon C. Physician-patient communication in decision-making about Caesarean sections in eight district hospitals in Bangladesh: a mixed-method study. Reprod Health 2021; 18:34. [PMID: 33563303 PMCID: PMC7871368 DOI: 10.1186/s12978-021-01098-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Caesarean sections (CS) in Bangladesh have risen eight-fold in the last 15 years. Few studies have explored why. Anecdotally, physicians suggest maternal request for CS is a reason. Women and families suggest physicians influence their decision-making. The aim of this research was to understand more about the decision-making process surrounding CS by exploring physician–patient communication leading to informed-consent for the operation. Methods We conducted a mixed-method study using structured observations with the Option Grid Collaborative’s OPTION5 tool and interviews with physicians and women between July and December 2018. Study participants were recruited from eight district public-sector hospitals. Eligibility criteria for facilities was ≥ 80 births every month; and for physicians, was that they had performed CSs. Women aged ≥ 18 years, providing consent, and delivering at a facility were included in the observation component; primigravid women delivering by CS were selected for the in-depth interviews. Quantitative data from observations were analysed using descriptive statistics. Following transcription and translation, a preliminary coding framework was devised for the qualitative data analysis. We combined both inductive and deductive approaches in our thematic analysis. Results In total, 306 labour situations were observed, and interviews were conducted with 16 physicians and 32 women who delivered by CS (16 emergency CS; 16 elective CS). In 92.5% of observations of physician–patient communication in the context of labour situations, the OPTION5 mean scores were low (5–25 out of 100) for presenting options, patient partnership, describing pros/cons, eliciting patient preferences and integrating patient preferences. Interviews found that non-clinical factors prime both physicians and patients in favour of CS prior to the clinical encounter in which the decision to perform a CS is documented. These interactions were both minimal in content and limited in purpose, with consent being an artefact of a process involving little communication. Conclusions Insufficient communication between physicians and patients is one of many factors driving increasing rates of caesarean section in Bangladesh. While this single clinical encounter provides an opportunity for practice improvement, interventions are unlikley to impact rates of CS without simultaneoulsy addressing physician, patient and health system contextual factors too.
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Affiliation(s)
| | - Sk Masum Billah
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh.,Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Camperdown, NSW, Australia
| | - Farhana Karim
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
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Ochieng Arunda M, Agardh A, Asamoah BO. Cesarean delivery and associated socioeconomic factors and neonatal survival outcome in Kenya and Tanzania: analysis of national survey data. Glob Health Action 2020; 13:1748403. [PMID: 32345146 PMCID: PMC7241493 DOI: 10.1080/16549716.2020.1748403] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/24/2020] [Indexed: 01/06/2023] Open
Abstract
Background: The increasing trends in cesarean delivery are globally acknowledged. However, in many low-resource countries, socioeconomic disparities have created a pattern of underuse and overuse among lower and higher socioeconomic groups. The impact of rising cesarean delivery rates on neonatal survival is also unclear.Objective: To examine cesarean delivery and its associated socioeconomic patterns and neonatal survival outcome in Kenya and Tanzania.Methods: We employed binary logistic regression to analyze cross-sectional demographic and health survey data on neonates born in health facilities in Kenya (2014) and Tanzania (2016).Results: Cesarean delivery rates ranged from 5% among uneducated, rural Tanzanian women to 26% among educated urban women in Kenya to 37.5% among managers in urban Tanzania. Overall findings indicated higher odds of cesarean delivery among mothers from richest households, adjusted odds ratio (aOR) 1.4 (95% CI 1.2-1.8), those insured, aOR 1.6 (95% CI 1.3-1.9), highly educated, aOR 1.6 (95% CI 1.2-2.0) and managers aOR 1.7 (95% CI 1.3-2.2), compared to middle class, no insurance, primary education and unemployed, respectively. Overall, compared to normal births and while adjusting for maternal risk factors, cesarean delivery was significantly associated with neonatal mortality in Kenya and Tanzania, overall aOR 1.7 (95% CI 1.2-2.7). However, statistical significance ceased when fetal risk factors and number of antenatal care visits were further controlled for, aOR 1.6 (95% CI 0.9-2.6).Conclusion: Disproportionate access to cesarean delivery has widened in Kenya and Tanzania. Higher risks of cesarean-related neonatal deaths exist. Medically indicated or not, the safety and/or choice of cesarean delivery is best addressed on individual basis at the health-facility level. However, policy initiatives to eliminate incentives, improve equitable access and accountability to reduce unnecessary cesarean deliveries through well-informed decisions are needed. Efforts to prevent unintended pregnancies among adolescents as well as training of health workers and continuous research to improve neonatal outcomes are vital.
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Affiliation(s)
- Malachi Ochieng Arunda
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Anette Agardh
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Benedict Oppong Asamoah
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
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Abubeker FA, Gashawbeza B, Gebre TM, Wondafrash M, Teklu AM, Degu D, Bekele D. Analysis of cesarean section rates using Robson ten group classification system in a tertiary teaching hospital, Addis Ababa, Ethiopia: a cross-sectional study. BMC Pregnancy Childbirth 2020; 20:767. [PMID: 33298012 PMCID: PMC7727107 DOI: 10.1186/s12884-020-03474-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cesarean section (CS) is an important indicator of access to, and quality of maternal health services. The World Health Organization recommends the Robson ten group classification system as a global standard for assessing, monitoring and comparing CS rates at all levels. This study aimed to assess the rate of CS and perform an analysis based on Robson classification system. METHODS A facility-based cross-sectional study was conducted at a tertiary hospital in Addis Ababa, Ethiopia. Data were collected from medical charts of all women who delivered from January-June 2018. The overall CS rate was calculated then women were categorized into one of the ten Robson groups. Relative size of each group, contribution of each group to the overall CS rate, and CS rate within each group were calculated. RESULTS A total of 4,200 deliveries were analyzed. Of these 1,459 (34.7%) were CS. The largest contributors to the overall CS rate were Group 10 (19.1%), Group 2 (18.3%), Group 5 (17.1%), and Group 4 (15.8%). There was also a high rate of pre-labor CS in Group 2, Group 4, and Group 10. CONCLUSION Through implementation of the Robson ten group classification system, we identified the contribution of each group to the overall CS rate as well as the CS rate within each group. Group 10 was the leading contributor to the overall CS rate. This study also revealed a high rate of CS among low-risk groups. These target groups require more in-depth analysis to identify possible modifiable factors and to apply specific interventions to reduce the CS rate. Evaluation of existing management protocols and further studies into indications of CS and outcomes are needed to design tailored strategies and improve outcomes.
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Affiliation(s)
- Ferid A Abubeker
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
| | - Biruck Gashawbeza
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Thomas Mekuria Gebre
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mekitie Wondafrash
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Demis Degu
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Delayehu Bekele
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Bakker W, Bakker E, Huigens C, Kaunda E, Phiri T, Beltman J, van Roosmalen J, van den Akker T. Impact of Medical Doctors Global Health and Tropical Medicine on decision-making in caesarean section: a pre- and post-implementation study in a rural hospital in Malawi. HUMAN RESOURCES FOR HEALTH 2020; 18:87. [PMID: 33168014 PMCID: PMC7650186 DOI: 10.1186/s12960-020-00516-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/17/2020] [Indexed: 06/05/2023]
Abstract
BACKGROUND Medical doctors with postgraduate training in Global Health and Tropical Medicine (MDGHTM) from the Netherlands, a high-income country with a relatively low caesarean section rate, assist associate clinicians in low-income countries regarding decision-making during labour. Objective of this study was to assess impact of the presence of MDGHTMs in a rural Malawian hospital on caesarean section rate and indications. METHODS This retrospective pre- and post-implementation study was conducted in a rural hospital in Malawi, where MDGHTMs were employed from April 2015. Indications for caesarean section were audited against national protocols and defined as supported or unsupported by these protocols. Caesarean section rates and numbers of unsupported indications for the years 2015 and 2016 per quarter for different staff cadres were assessed by linear regression. RESULTS Six hundred forty-five women gave birth by caesarean section in the study period. The caesarean rate dropped from 20.1 to 12.8% (p < 0.05, R2 = 0.53, y = - 0.0086x + 0.2295). Overall 132 of 501 (26.3%) auditable indications were not supported by documentation in medical records. The proportion of unsupported indications dropped significantly over time from 47.0 to 4.4% (p < 0.01, R2 = 0.71, y = - 0.0481x + 0.4759). Stratified analysis for associate clinicians only (excluding caesarean sections performed by medical doctors) showed a similar decrease from 48.3 to 6.5% (p < 0.05, R2 = 0.55, y = - 0.0442x + 0.4805). CONCLUSIONS Our results indicate that presence of MDGHTMs was accompanied by considerable decreases in caesarean section rate and proportion of unsupported indications for caesarean section in this facility. Their presence is likely to have influenced decision-making by associate clinicians.
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Affiliation(s)
- Wouter Bakker
- Clinical Department, St. Luke's Hospital, Malosa, Malawi.
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands.
| | - Emma Bakker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Emily Kaunda
- Nursing and Midwifery Department, St. Luke's Hospital, Malosa, Malawi
| | - Timothy Phiri
- Clinical Department, St. Luke's Hospital, Malosa, Malawi
| | - Jogchum Beltman
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jos van Roosmalen
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas van den Akker
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
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Abdo AA, Hinderaker SG, Tekle AG, Lindtjørn B. Caesarean section rates analysed using Robson's 10-Group Classification System: a cross-sectional study at a tertiary hospital in Ethiopia. BMJ Open 2020; 10:e039098. [PMID: 33115900 PMCID: PMC7594350 DOI: 10.1136/bmjopen-2020-039098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess the caesarean section (CS) rates using Robson's 10-Group Classification System among women who gave birth at Hawassa University Referral Hospital in southern Ethiopia. DESIGN Cross-sectional study design to determine CS rate using Robson's 10-Group Classification System. SETTING Hawassa University Referral Hospital in south Ethiopia. PARTICIPANTS 4004 women who gave birth in Hawassa University Referral Hospital from June 2018 to June 2019. RESULTS The 4004 women gave birth to 4165 babies. The overall CS rate was 32.8% (95% CI: 31.4%-34.3%). The major contributors to the overall CS rates were: Robson group 1 (nulliparous women with singleton pregnancy at term in spontaneous labour) 22.9%; group 5 (multiparous women with at least one previous CS) 21.4% and group 3 (multiparous women without previous CS, with singleton pregnancy in spontaneous labour) 17.3%. The most commonly reported indications for CS were 'fetal compromise' (35.3%) followed by previous CS (20.3%) and obstructed labour (10.7%). CONCLUSION A high proportion of women giving birth at this hospital were given a CS, and many of them were in a low-risk group. Few had trial of labour. More active use of partogram, improving fetal heartbeat-monitoring system, implementing midwife-led care, involving a companion during labour and auditing the appropriateness of CS indications may help to reduce the CS rate.
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Affiliation(s)
- Abdella Amano Abdo
- Epidemiology, Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
| | | | | | - Bernt Lindtjørn
- Center for International Health, University of Bergen, Bergen, Norway
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Mulinganya G, Bwenge Malembaka E, Lukula Akonkwa M, Mpunga Mukendi D, Kajibwami Birindwa E, Maheshe Balemba G, Temmerman M, Tambwe AM, Criel B, Bisimwa Balaluka G. Applying the Robson classification to routine facility data to understand the Caesarean section practice in conflict settings of South Kivu, eastern DR Congo. PLoS One 2020; 15:e0237450. [PMID: 32898139 PMCID: PMC7478810 DOI: 10.1371/journal.pone.0237450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/27/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Sub-Saharan Africa has low Caesarean (CS) levels, despite a global increase in CS use. In conflict settings, the pattern of CS use is unclear because of scanty data. We aimed to examine the opportunity of using routine facility data to describe the CS use in conflict settings. METHODS We conducted a facility-based cross-sectional study in 8 health zones (HZ) of South Kivu province in eastern DR Congo. We reviewed patient hospital records, maternity registers and operative protocol books, from January to December 2018. Data on direct conflict fatalities were obtained from the Uppsala Conflict Data Program. Based on conflict intensity and chronicity (expressed as a 6-year cumulative conflict death rate), HZ were classified as unstable (higher conflict death rate), intermediate and stable (lower conflict death rate). To describe the Caesarean section practice, we used the Robson classification system. Based on parity, history of previous CS, onset of labour, foetal lie and presentation, number of neonates and gestational age, the Robson classification categorises deliveries into 10 mutually exclusive groups. We performed a descriptive analysis of the relative contribution of each Robson group to the overall CS rate in the conflict stratum. RESULTS Among the 29,600 deliveries reported by health facilities, 5,520 (18.6%) were by CS; 5,325 (96.5%) records were reviewed, of which 2,883 (54.1%) could be classified. The overall estimated population CS rate was 6.9%. The proportion of health facility deliveries that occurred in secondary hospitals was much smaller in unstable health zones (22.4%) than in intermediate (40.25) or stable health zones (43.0%). Robson groups 5 (previous CS, single cephalic, ≥ 37 weeks), 1 (nulliparous, single cephalic, ≥ 37 weeks, spontaneous labour) and 3 (multiparous, no previous CS, single cephalic, ≥ 37 weeks, spontaneous labour) were the leading contributors to the overall CS rate; and represented 75% of all CS deliveries. In unstable zones, previous CS (27.1%) and abnormal position of the fetus (breech, transverse lie, 3.3%) were much less frequent than in unstable and intermediate (44.3% and 6.0% respectively) and stable (46.7%and 6.2% respectively). Premature delivery and multiple pregnancy were more prominent Robson groups in unstable zones. CONCLUSION In South Kivu province, conflict exposure is linked with an uneven estimated CS rate at HZ level with at high-risks women in conflict affected settings likely to have lower access to CS compared to low-risk mothers in stable health zones.
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Affiliation(s)
- Guy Mulinganya
- Department of Gynecology and Obstetrics, Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
| | - Espoir Bwenge Malembaka
- Ecole Régionale de Santé Publique, ERSP, Faculté de Médecine, Univesité Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Institute of Health and Society, IRSS, Ecole de Santé Publique, Université Catholique de Louvain, Brussels, Belgium
- * E-mail: ,
| | - Melissa Lukula Akonkwa
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
- Ecole Régionale de Santé Publique, ERSP, Faculté de Médecine, Univesité Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Dieudonné Mpunga Mukendi
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Etienne Kajibwami Birindwa
- Department of Gynecology and Obstetrics, Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Ghislain Maheshe Balemba
- Ecole Régionale de Santé Publique, ERSP, Faculté de Médecine, Univesité Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Department of Radiology, Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Marleen Temmerman
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Centre of Excellence in Women and Child Health, School of Medicine, Aga Khan University, Nairobi, Kenya
| | - Albert Mwembo Tambwe
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
- Ecole de Santé Publique, Université de Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Bart Criel
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Ghislain Bisimwa Balaluka
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
- Ecole Régionale de Santé Publique, ERSP, Faculté de Médecine, Univesité Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Université du Cinquantenaire de Lwiro, Lwiro, Democratic Republic of Congo
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Makokha-Sandell H, Mgaya A, Belachew J, Litorp H, Hussein K, Essén B. Low use of vacuum extraction: Health care Professionals' Perspective in a University Hospital, Dar es Salaam. SEXUAL & REPRODUCTIVE HEALTHCARE 2020; 25:100533. [PMID: 32505920 DOI: 10.1016/j.srhc.2020.100533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Use of vacuum extraction (VE) has been declining in low and middle income countries. At the highest referral hospital Tanzania, 54% of deliveries are performed by caesarean section (CS) and only 0.8% by VE. Use of VE has the potential to reduce CS rates and improve maternal and neonatal outcomes but causes for its low use is not fully explored. METHOD During November and December of 2017 participatory observations, semi-structured in-depth interviews (n = 29) and focus group discussions (n = 2) were held with midwives, residents and specialists working at the highest referral hospital in Tanzania. Thematic analysis was used to identify rationales for low VE use. FINDINGS Unstructured and inconsistent clinical teaching structure, interdependent on a fear and blame culture, as well as financial incentives and a lack of structured, adhered to and updated guidelines were identified as rationales for CS instead of VE use. Although all informants showed positivity towards clinical teaching of VE, a subpar communication between clinics and academia was stated as resulting in absent clinical teachers and unaccountable students. CONCLUSION This study draws connections between the low use of VE and the inconsistent and unstructured clinical training of VE expressed through the health care providers' points of view. However, clinical teaching in VE was highly welcomed by the informers which may serve as a good starting point for future interventions.
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Affiliation(s)
- Henrik Makokha-Sandell
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden.
| | - Andrew Mgaya
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden; Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania.
| | - Johanna Belachew
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden.
| | - Helena Litorp
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden.
| | - Kidanto Hussein
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden; Medical College, East Africa, Aga Khan University, P.O. Box 38129, Dar es Salaam, Tanzania; Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Birgitta Essén
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden.
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Du SG, Tang F, Zhao Y, Sun GQ, Lin Y, Tan ZH, Wu XF. Effect of China's Universal Two-child Policy on the Rate of Cesarean Delivery: A Case Study of a Big Childbirth Center in China. Curr Med Sci 2020; 40:348-353. [PMID: 32337696 DOI: 10.1007/s11596-020-2190-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 02/04/2020] [Indexed: 10/24/2022]
Abstract
China's universal two-child policy was released in October of 2015. How would this new policy influence the rate of overall cesarean delivery (CD) in China? The objective of this paper is to investigate the trend of overall CD rate with the increase of number of multiparous women based on a big childbirth center of China (a tertiary hospital) in 2016. In this study, 22 530 cases from the medical record department of a big childbirth center of China from January 1 to December 31 in 2016 were enrolled as research objects. Electronic health records of these selected objects were retrieved. According to the history of childbirth, the selected cases were divided into primiparous group containing 16 340 cases and multiparous group containing 6190 cases. Chi-square test was carried out to compare the rate of CD, neuraxial labor analgesia, maternity insurance between the two groups; t-test was performed to compare the in-hospital days and gestational age at birth between the two groups. Pearson correlation coefficient was used to evaluate the relationship among observed monthly rate of multiparas, overall CD rate, and Elective Repeat Cesarean Delivery (ERCD) rate. The results showed that the CD rate in multiparous group was 55.46%, which was higher than that in primiparous group (34.66%, P<0.05). The rate of neuraxial labor analgesia in multiparas group was 9.29%, which was lower than that in primiparas group (35.94%, P<0.05). However, the rate of maternity insurance was higher in multiparas group (57.00%) than that in primiparas group (41.08%, P<0.05). The hospital cost and in-hospital days in multiparas group were higher, and the gestational age at birth in multiparas group was lower than in primiparas group (P<0.05). The overall CD rate slightly dropped in the first 4 months of the year (P<0.05), then increased from 36.27% (April) to 43.21% (December) (P<0.05). The rate of multiparas women and ERCD had the same trend (P<0.05). There were linear correlations among the rate of overall CD, the rate of multiparas women and the rate of ERCD rate (P<0.05). With the opening of China's two-child policy, the increasing rate of overall CD is directly related with the high rate of ERCD. Trials of Labor After Cesarean Section (TOLAC) in safe mode to reduce overall CD rate are warranted in the future.
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Affiliation(s)
- Shu-Guo Du
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Affiliated Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China
| | - Fei Tang
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Affiliated Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China
| | - Yun Zhao
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Affiliated Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China.
| | - Guo-Qiang Sun
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Affiliated Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China
| | - Ying Lin
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Affiliated Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China
| | - Zhi-Hua Tan
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Affiliated Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China
| | - Xu-Feng Wu
- Department of Gynecology and Oncology, Maternal and Child Health Hospital of Hubei Province, Affiliated Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China
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Bączek G, Tataj-Puzyna U, Sys D, Baranowska B. Freestanding Midwife-Led Units: A Narrative Review. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2020; 25:181-188. [PMID: 32724762 PMCID: PMC7299417 DOI: 10.4103/ijnmr.ijnmr_209_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/04/2020] [Accepted: 03/09/2020] [Indexed: 11/04/2022]
Abstract
Background Strengthening of midwives' position and support for freestanding birth centers, frequently referred to as Freestanding Midwife-led Units (FMUs), raise hopes for a return to humanized labor. Our study aimed to review published evidence regarding FMUs to systematize the knowledge of their functioning and to identify potential gaps in this matter. Materials and Methods A structured integrative review of theoretical papers and empirical studies was conducted. The literature search included MEDLINE, Cochrane, Scopus, and Embase databases. The analysis included papers published in 1977-2017. Relevant documents were identified using various combinations of search terms and standard Boolean operators. The search included titles, abstracts, and keywords. Additional records were found through a manual search of reference lists from extracted papers. Results Overall, 56 out of 107 originally found articles were identified as eligible for the review. Based on the critical analysis of published data, six groups of research problems were identified and discussed, namely, 1) specifics of FMUs, 2) costs of perinatal care at FMUs, 3) FMUs as a place for midwife education, 4) FMUs from midwives' perspective, 5) perinatal, maternal, and neonatal outcomes, and 6) FMUs from the perspective of a pregnant woman. Conclusions FMUs offers a home-like environment and complex midwifery support for women with uncomplicated pregnancies. Although emergency equipment is available as needed, FMU birth is considered a natural spontaneous process. Midwives' supervision over low-risk labors may provide many benefits, primarily related to lower medicalization and fewer medical interventions than in a hospital setting.
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Affiliation(s)
- Grażyna Bączek
- Department of Obstetrics and Gynecology Didactics, Medical University of Warsaw, Warszawa, Poland
| | - Urszula Tataj-Puzyna
- Department of Obstetrics and Gynecology Didactics, Medical University of Warsaw, Warszawa, Poland
| | - Dorota Sys
- Department of Reproductive Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Barbara Baranowska
- Department of Midwifery, Centre of Postgraduate Medical Education, Warsaw, Poland
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Ngongo CJ, Raassen T, Lombard L, van Roosmalen J, Weyers S, Temmerman M. Delivery mode for prolonged, obstructed labour resulting in obstetric fistula: a retrospective review of 4396 women in East and Central Africa. BJOG 2020; 127:702-707. [PMID: 31846206 PMCID: PMC7187175 DOI: 10.1111/1471-0528.16047] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula. DESIGN Retrospective record review. SETTING Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia. POPULATION A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014. METHODS Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries. MAIN OUTCOME MEASURES Mode of delivery, stillbirth. RESULTS Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514). CONCLUSIONS In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth. TWEETABLE ABSTRACT Caesarean section is increasingly performed in African women with stillbirth treated for obstetric fistula.
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Affiliation(s)
| | | | | | - J van Roosmalen
- Athena Institute VU University Amsterdam, Amsterdam, the Netherlands.,Leiden University Medical Centre, Leiden, the Netherlands
| | - S Weyers
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium
| | - M Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya.,Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
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Tognon F, Borghero A, Putoto G, Maziku D, Torelli GF, Azzimonti G, Betran AP. Analysis of caesarean section and neonatal outcome using the Robson classification in a rural district hospital in Tanzania: an observational retrospective study. BMJ Open 2019; 9:e033348. [PMID: 31822545 PMCID: PMC6924846 DOI: 10.1136/bmjopen-2019-033348] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Caesarean section (CS) rates have increased worldwide in recent decades. In 2015, the WHO proposed the use of the 10-group Robson classification as a global standard for assessing, monitoring and comparing CS rates both within healthcare facilities over time and between them. The aim of this study was to assess the pattern of CS rates according to the Robson classification and describe maternal and perinatal outcomes by group at the Tosamaganga Hospital in rural Tanzania. DESIGN Observational retrospective study. SETTING St. John of the Cross Tosamaganga Hospital, a referral centre in rural Tanzania. PARTICIPANTS 3012 women who gave birth in Tosamaganga Hospital from 1 January to 30 June 2014 and from 1 March to 30 November 2015. RESULTS The overall CS rate was 35.2%, and about 90% of women admitted for labour were in Robson groups 1 through 5. More than 40% of the CS carried out in the hospital were performed on nulliparous women at term with a single fetus in cephalic presentation (groups 1 and 3), and the most frequent indication for the procedure was previous uterine scar (39.2%). The majority of severe neonatal outcomes were observed in groups 1 (27.7%), 10 (24.5%) and 3 (19.1%). CONCLUSION We recorded a high CS rate in Tosamaganga Hospital, particularly in low-risk patients groups (Robson groups 1 and 3). Our analysis of Robson classification and neonatal outcomes suggests the need to improve labour management at the hospital and to provide timely referrals in order to prevent women from arriving there in critical conditions.
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Affiliation(s)
- Francesca Tognon
- Dipartimento di Salute della Donna e del Bambino, Universita degli Studi di Padova Dipartimento di Medicina, Padova, Italy
- Research Unit, Cuamm Medici con l'Africa, Padova, Veneto, Italy
| | - Angela Borghero
- Tosamaganga Council Designated Hospital, Cuamm Medici con l'Africa, Iringa, United Republic of Tanzania
| | - Giovanni Putoto
- Research Unit, Cuamm Medici con l'Africa, Padova, Veneto, Italy
| | - Donald Maziku
- Maternity Department, Tosamaganga Council Designated Hospital, Iringa, United Republic of Tanzania
| | - Giovanni Fernando Torelli
- Tosamaganga Council Designated Hospital, Cuamm Medici con l'Africa, Iringa, United Republic of Tanzania
| | - Gaetano Azzimonti
- Tosamaganga Council Designated Hospital, Cuamm Medici con l'Africa, Iringa, United Republic of Tanzania
| | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Ogbo FA, Ezeh OK, Awosemo AO, Ifegwu IK, Tan L, Jessa E, Charwe D, Agho KE. Determinants of trends in neonatal, post-neonatal, infant, child and under-five mortalities in Tanzania from 2004 to 2016. BMC Public Health 2019; 19:1243. [PMID: 31500599 PMCID: PMC6734430 DOI: 10.1186/s12889-019-7547-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 08/26/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Under-five mortality is still a major health issue in many developing countries like Tanzania. To achieve the Sustainable Development Goal target of ending preventable child deaths in Tanzania, a detailed understanding of the risk factors for under-five deaths is essential to guide targeted interventions. This study aimed to investigate trends and determinants of neonatal, post-neonatal, infant, child and under-five mortalities in Tanzania from 2004 to 2016. METHODS The study used combined data from the 2004-2005, 2010 and 2015-2016 Tanzania Demographic and Health Surveys, with a sample of 25,951 singletons live births and 1585 under-five deaths. We calculated age-specific mortality rates, followed by an assessment of trends and determinants (community, socioeconomic, individual and health service) of neonatal, postneonatal, infant, child and under-five mortalities in Cox regression models. The models adjusted for potential confounders, clustering and sampling weights. RESULTS Between 2004 and 2016, we found that neonatal mortality rate remained unchanged, while postneonatal mortality and child mortality rates have halved in Tanzania. Infant mortality and under-five mortality rates have also declined. Mothers who gave births through caesarean section, younger mothers (< 20 years), mothers who perceived their babies to be small or very small and those with fourth or higher birth rank and a short preceding birth interval (≤2 years) reported higher risk of neonatal, postneonatal and infant mortalities. CONCLUSION Our study suggests that there was increased survival of children under-5 years in Tanzania driven by significant improvements in postneonatal, infant and child survival rates. However, there remains unfinished work in ending preventable child deaths in Tanzania.
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Affiliation(s)
- Felix Akpojene Ogbo
- Translational Health Research Institute (THRI), School of Medicine, Western Sydney University, Penrith, NSW 2751 Australia
- General Practice Unit, Prescot Specialist Medical Centre, Welfare Quarters, Makurdi, Benue State Nigeria
| | - Osita Kingsley Ezeh
- School of Science and Health, Western Sydney University, Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2571 Australia
| | - Akorede O. Awosemo
- General Practice Unit, Prescot Specialist Medical Centre, Welfare Quarters, Makurdi, Benue State Nigeria
| | - Ifegwu K. Ifegwu
- General Practice Unit, Prescot Specialist Medical Centre, Welfare Quarters, Makurdi, Benue State Nigeria
| | - Lawrence Tan
- Department of General Practice, School of Medicine, Western Sydney University, Penrith, NSW 2751 Australia
| | - Emmanuel Jessa
- Department of General Practice, School of Medicine, Western Sydney University, Penrith, NSW 2751 Australia
| | - Deborah Charwe
- Tanzania Food and Nutrition Centre, No 22. Ocean Road, Dar es Salaam, Tanzania
| | - Kingsley Emwinyore Agho
- Translational Health Research Institute (THRI), School of Medicine, Western Sydney University, Penrith, NSW 2751 Australia
- School of Science and Health, Western Sydney University, Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2571 Australia
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Ushie BA, Udoh EE, Ajayi AI. Examining inequalities in access to delivery by caesarean section in Nigeria. PLoS One 2019; 14:e0221778. [PMID: 31465505 PMCID: PMC6715280 DOI: 10.1371/journal.pone.0221778] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/14/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Maternal deaths are far too common in Nigeria, and this is in part due to lack of access to lifesaving emergency obstetric care, especially among women in the poorest strata in Nigeria. Data on the extent of inequality in access to such lifesaving intervention could convince policymakers in developing an appropriate intervention. This study examines inequality in access to births by caesarean section in Nigeria. METHODS Data for 20,468 women who gave birth in the five years preceding 2013 Nigerian Demographic and Health Survey (DHS) were used for this study. Inequality in caesarean delivery was assessed using the concentration curve and multiple logistic regression models. RESULTS There was a high concentration in the utilisation of caesarean section among the women in the relatively high wealth quintile. Overall, delivery by caesarean section was 2.1%, but the rate was highest among women who had higher education and belonged to the richest wealth quintile (13.6%) and lowest among women without formal education and who belonged to the poorest wealth quintile (0.4%). Belonging to the poorest wealth quintile and having no formal education were associated with lower odds of having delivery by caesarean section. CONCLUSION In conclusion, women in the richest households are within the WHO's recommended level of 10-15% for caesarean birth utilisation, but women in the poorest households are so far away from the recommended rate. Equity in healthcare is still a promise, its realisation will entail making care available to those in need not only those who can afford it.
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Affiliation(s)
- Boniface Ayanbekongshie Ushie
- Population Dynamics and Reproductive Health Unit, African Population and Health Research Centre, APHRC Campus, Nairobi, Kenya
| | | | - Anthony Idowu Ajayi
- Population Dynamics and Reproductive Health Unit, African Population and Health Research Centre, APHRC Campus, Nairobi, Kenya
- * E-mail:
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Rivenes Lafontan S, Kidanto HL, Ersdal HL, Mbekenga CK, Sundby J. Perceptions and experiences of skilled birth attendants on using a newly developed strap-on electronic fetal heart rate monitor in Tanzania. BMC Pregnancy Childbirth 2019; 19:165. [PMID: 31077139 PMCID: PMC6511185 DOI: 10.1186/s12884-019-2286-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 04/12/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Regular fetal heart rate monitoring during labor can drastically reduce fresh stillbirths and neonatal mortality through early detection and management of fetal distress. Fetal monitoring in low-resource settings is often inadequate. An electronic strap-on fetal heart rate monitor called Moyo was introduced in Tanzania to improve intrapartum fetal heart rate monitoring. There is limited knowledge about how skilled birth attendants in low-resource settings perceive using new technology in routine labor care. This study aimed to explore the attitude and perceptions of skilled birth attendants using Moyo in Dar es Salaam, Tanzania. METHODS A qualitative design was used to collect data. Five focus group discussions and 10 semi-structured in-depth interviews were carried out. In total, 28 medical doctors and nurse/midwives participated in the study. The data was analyzed using qualitative content analysis. RESULTS The participants in the study perceived that the device was a useful tool that made it possible to monitor several laboring women at the same time and to react faster to fetal distress alerts. It was also perceived to improve the care provided to the laboring women. Prior to the introduction of Moyo, the participants described feeling overwhelmed by the high workload, an inability to adequately monitor each laboring woman, and a fear of being blamed for negative fetal outcomes. Challenges related to use of the device included a lack of adherence to routines for use, a lack of clarity about which laboring women should be monitored continuously with the device, and misidentification of maternal heart rate as fetal heart rate. CONCLUSION The electronic strap-on fetal heart rate monitor, Moyo, was considered to make labor monitoring easier and to reduce stress. The study findings highlight the importance of ensuring that the device's functions, its limitations and its procedures for use are well understood by users.
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Affiliation(s)
- Sara Rivenes Lafontan
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway
| | - Hussein L. Kidanto
- Medical College, East Africa, Aga Khan University, Dar es Salaam, Tanzania
- Department of Research, Stavanger University Hospital, Postboks 8100, 4068 Stavanger, Norway
| | - Hege L. Ersdal
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Postboks 8100, 4068 Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway
| | - Columba K. Mbekenga
- School of Nursing and Midwifery, Aga Khan University, Dar es Salaam, Tanzania
| | - Johanne Sundby
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway
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Kaboré C, Ridde V, Chaillet N, Yaya Bocoum F, Betrán AP, Dumont A. DECIDE: a cluster-randomized controlled trial to reduce unnecessary caesarean deliveries in Burkina Faso. BMC Med 2019; 17:87. [PMID: 31046752 PMCID: PMC6498483 DOI: 10.1186/s12916-019-1320-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/10/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In Burkina Faso, facility-based caesarean delivery rates have markedly increased since the national subsidy policy for deliveries and emergency obstetric care was implemented in 2006. Effective and safe strategies are needed to prevent unnecessary caesarean deliveries. METHODS We conducted a cluster-randomized controlled trial of a multifaceted intervention at 22 referral hospitals in Burkina Faso. The evidence-based intervention was designed to promote the use of clinical algorithms for caesarean decision-making using in-site training, audits and feedback of caesarean indications and SMS reminders. The primary outcome was the change in the percentage of unnecessary caesarean deliveries. Unnecessary caesareans were defined on the basis of the literature review and expert consensus. Data were collected daily using a standardized questionnaire, in the same way at both the intervention and control hospitals. Caesareans were classified as necessary or unnecessary in the same way, in both arms of the trial using a standardized computer algorithm. RESULTS A total of 2138 and 2036 women who delivered by caesarean section were analysed in the pre and post-intervention periods, respectively. A significant reduction in the percentage of unnecessary caesarean deliveries was evident from the pre- to post-intervention period in the intervention group compared with the control group (18.96 to 6.56% and 18.27 to 23.30% in the intervention and control groups, respectively; odds ratio [OR] for incremental change over time, adjusted for hospital and patient characteristics, 0.22; 95% confidence interval [CI], 0.14 to 0.34; P < 0.001; adjusted risk difference, - 17.02%; 95% CI, - 19.20 to - 13.20%). The intervention did not significantly affect the rate of maternal death (0.75 to 0.19% and 0.92 to 0.40% in the intervention and control groups, respectively; adjusted OR 0.32; 95% CI 0.04 to 2.23; P = 0.253) or intrapartum-related neonatal death (4.95 to 6.32% and 5.80 to 4.29% in the intervention and control groups, respectively, adjusted OR 1.73; 95% CI 0.82 to 3.66; P = 0.149). The overall perinatal mortality data were not available. CONCLUSION Promotion and training on clinical algorithms for decision-making, audit and feedback and SMS reminders reduced unnecessary caesarean deliveries, compared with usual care in a low-resource setting. TRIAL REGISTRATION The DECIDE trial is registered on the Current Controlled Trials website: ISRCTN48510263 .
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Affiliation(s)
- Charles Kaboré
- IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France. .,Research Institute of Health Sciences, Ouagadougou, Burkina Faso.
| | - Valéry Ridde
- IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France.,University of Montreal Public Health Research Institute (IRSPUM), Montreal, Canada
| | - Nils Chaillet
- Hospital Center of Laval University (CHUL), Quebec, Canada
| | | | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, CH-1211, Geneva 27, Switzerland
| | - Alexandre Dumont
- IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
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Pandit R, Jain V, Bagga R, Sikka P, Jain K. Applicability of WHO Maternal Severity Score (MSS) and Maternal Severity Index (MSI) Model to predict the maternal outcome in near miss obstetric patients: a prospective observational study. Arch Gynecol Obstet 2019; 300:49-57. [PMID: 30976972 DOI: 10.1007/s00404-019-05159-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/06/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the applicability of WHO Maternal Severity Score (MSS) and Maternal Severity Index (MSI) Model in near miss (NM) obstetric patients METHODS: It was a prospective observational study conducted at a tertiary health care center from July 2015 to Feb 2016. All patients fulfilling one or more WHO NM criteria were included. MSS and MSI were calculated for all NM patients on admission. They were then followed up till the final outcome (NM or death). Each NM parameter, system-wise MSS, total MSS and MSI were then associated with the final outcome. RESULTS Of 4822 patients, 1739 had potentially life-threatening conditions of which 174 were identified as NM. The average MSS and MSI of patients who remained NM was 4.41 and 11.67%, respectively, and those who died was 9.47 and 58.16%, respectively. Both were found to be significantly associated with the outcome (p < 0.001). MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC - 0.838 [95% CI 0.766-0.910]). However, of 25 NM criteria, only 17 NM criteria and 3 system dysfunctions (cardiovascular, respiratory and neurological) were found to associate significantly with the outcome. CONCLUSION MSS and MSI act as good prognostic tools to assess the severity of maternal complications and estimate the probability of death in NM patients. As all NM parameters are not equally predictive of severity of maternal morbidity, different scores per NM parameter and system should be assigned while calculating MSS for better prognostication.
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Affiliation(s)
- Rubina Pandit
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160011, India.
- Department of Reproductive Medicine, Cloudnine Hospital, Bangalore, India.
| | - Vanita Jain
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160011, India
| | - Rashmi Bagga
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160011, India
| | - Pooja Sikka
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160011, India
| | - Kajal Jain
- Department of Anesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kamala B, Kidanto H, Dalen I, Ngarina M, Abeid M, Perlman J, Ersdal H. Effectiveness of a Novel Continuous Doppler (Moyo) Versus Intermittent Doppler in Intrapartum Detection of Abnormal Foetal Heart Rate: A Randomised Controlled Study in Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E315. [PMID: 30678354 PMCID: PMC6388236 DOI: 10.3390/ijerph16030315] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/22/2019] [Accepted: 01/22/2019] [Indexed: 01/25/2023]
Abstract
Background: Intrapartum foetal heart rate (FHR) monitoring is crucial for identification of hypoxic foetuses and subsequent interventions. We compared continuous monitoring using a novel nine-crystal FHR monitor (Moyo) versus intermittent single crystal Doppler (Doppler) for the detection of abnormal FHR. Methods: An unmasked randomised controlled study was conducted in a tertiary hospital in Tanzania (ClinicalTrials.gov Identifier: NCT02790554). A total of 2973 low-risk singleton pregnant women in the first stage of labour admitted with normal FHR were randomised to either Moyo (n = 1479) or Doppler (1494) arms. The primary outcome was the proportion of abnormal FHR detection. Secondary outcomes were time intervals in labour, delivery mode, Apgar scores, and perinatal outcomes. Results: Moyo detected abnormal FHR more often (13.3%) compared to Doppler (9.8%) (p = 0.002). Time intervals from admission to detection of abnormal FHR were 15% shorter in Moyo (p = 0.12) and from the detection of abnormal FHR to delivery was 36% longer in Moyo (p = 0.007) compared to the Doppler arm. Time from last FHR to delivery was 12% shorter with Moyo (p = 0.006) compared to Doppler. Caesarean section rates were higher with the Moyo device compared to Doppler (p = 0.001). Low Apgar scores (<7) at the 1st and 5th min were comparable between groups (p = 0.555 and p = 0.800). Perinatal outcomes (fresh stillbirths and 24-h neonatal deaths) were comparable at delivery (p = 0.497) and 24-h post-delivery (p = 0.345). Conclusions: Abnormal FHR detection rates were higher with Moyo compared to Doppler. Moyo detected abnormal FHR earlier than Doppler, but time from detection to delivery was longer. Studies powered to detect differences in perinatal outcomes with timely responses are recommended.
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Affiliation(s)
- Benjamin Kamala
- Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway.
- Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania.
| | - Hussein Kidanto
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway.
- School of Medicine, Aga Khan University, P.O. Box 38129, Dar es Salaam, Tanzania.
| | - Ingvild Dalen
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway.
| | - Matilda Ngarina
- Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania.
| | - Muzdalifat Abeid
- School of Medicine, Aga Khan University, P.O. Box 38129, Dar es Salaam, Tanzania.
| | - Jeffrey Perlman
- Department of Paediatrics, Weill Cornell Medicine, New York, NY 10065, USA.
| | - Hege Ersdal
- Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway.
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, 4011 Stavanger, Norway.
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Hanson C, Betrán AP, Opondo C, Mkumbo E, Manzi F, Mbaruku G, Schellenberg J. Trends in caesarean section rates between 2007 and 2013 in obstetric risk groups inspired by the Robson classification: results from population‐based surveys in a low‐resource setting. BJOG 2018; 126:690-700. [DOI: 10.1111/1471-0528.15534] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2018] [Indexed: 11/28/2022]
Affiliation(s)
- C Hanson
- Department of Public Health Sciences Karolinska Institutet Stockholm Sweden
- Department of Disease Control London School of Hygiene and Tropical Medicine London UK
| | - AP Betrán
- Department of Reproductive Health and Research UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction World Health Organization Geneva Switzerland
| | - C Opondo
- Department of Disease Control London School of Hygiene and Tropical Medicine London UK
| | - E Mkumbo
- Ifakara Health Institute Dar‐es‐Salaam Tanzania
| | - F Manzi
- Ifakara Health Institute Dar‐es‐Salaam Tanzania
| | - G Mbaruku
- Ifakara Health Institute Dar‐es‐Salaam Tanzania
| | - J Schellenberg
- Department of Disease Control London School of Hygiene and Tropical Medicine London UK
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Saleh Gargari S, Essén B, Fallahian M, Mulic-Lutvica A, Mohammadi S. Auditing the appropriateness of cesarean delivery using the Robson classification among women experiencing a maternal near miss. Int J Gynaecol Obstet 2018; 144:49-55. [PMID: 30353540 DOI: 10.1002/ijgo.12698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 08/08/2018] [Accepted: 10/22/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate appropriateness of cesarean delivery and cesarean delivery-related morbidity among maternal near misses (MNMs) using the Robson ten-group classification system. METHODS In the present audit study, medical records were assessed for women who experienced MNM and underwent cesarean delivery at three university hospitals in Tehran, Iran, between March 1, 2012, and May 1, 2014. Local auditors assessed cesarean delivery indications and morbidity experienced. All records were re-assessed using Swedish obstetric guidelines. Findings were reported using the Robson ten-group classification system. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS Of the 61 women included, cesarean deliveries were more likely to be considered appropriate by local auditors compared with Swedish ones (OR 2.7, 95% CI 1.3-5.7). Cesarean delivery-related morbidity was attributed to near-miss events for 10 (16%) MNMs and was found to have aggravated 25 (41%). Of 16 women classified as Robson group 1-4, cesarean delivery-related MNM was identified in 15 (94%), compared with 13 (43%) of 30 women in group 10. Cesarean delivery with appropriate indication was associated with very low likelihood of cesarean delivery-related MNM (OR 0.2, 95% CI 0.1-0.6). CONCLUSION Cesarean delivery in the absence of appropriate indication could be an unsafe delivery choice. Audits using the Robson classification system facilitate understanding inappropriate cesarean delivery and its impact on maternal health.
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Affiliation(s)
- Soraya Saleh Gargari
- Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Birgitta Essén
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Masoumeh Fallahian
- Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ajlana Mulic-Lutvica
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Soheila Mohammadi
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
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Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, Gibbons D, Kelly NM, Kennedy HP, Kidanto H, Taylor P, Temmerman M. Short-term and long-term effects of caesarean section on the health of women and children. Lancet 2018; 392:1349-1357. [PMID: 30322585 DOI: 10.1016/s0140-6736(18)31930-5] [Citation(s) in RCA: 589] [Impact Index Per Article: 98.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/06/2018] [Accepted: 08/10/2018] [Indexed: 02/08/2023]
Abstract
A caesarean section (CS) can be a life-saving intervention when medically indicated, but this procedure can also lead to short-term and long-term health effects for women and children. Given the increasing use of CS, particularly without medical indication, an increased understanding of its health effects on women and children has become crucial, which we discuss in this Series paper. The prevalence of maternal mortality and maternal morbidity is higher after CS than after vaginal birth. CS is associated with an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth, and these risks increase in a dose-response manner. There is emerging evidence that babies born by CS have different hormonal, physical, bacterial, and medical exposures, and that these exposures can subtly alter neonatal physiology. Short-term risks of CS include altered immune development, an increased likelihood of allergy, atopy, and asthma, and reduced intestinal gut microbiome diversity. The persistence of these risks into later life is less well investigated, although an association between CS use and greater incidence of late childhood obesity and asthma are frequently reported. There are few studies that focus on the effects of CS on cognitive and educational outcomes. Understanding potential mechanisms that link CS with childhood outcomes, such as the role of the developing neonatal microbiome, has potential to inform novel strategies and research for optimising CS use and promote optimal physiological processes and development.
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Affiliation(s)
- Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, St Thomas' Hospital Campus, King's College London, London UK.
| | - Rachel M Tribe
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, St Thomas' Hospital Campus, King's College London, London UK
| | - Lisa Avery
- Department of Community Health Sciences, Centre for Global Public Health, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Glen Mola
- School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea; Department of Obstetrics and General Hospital, Port Moresby, Papua New Guinea
| | - Gerard Ha Visser
- International Federation of Gynecology and Obstetrics (FIGO), London, UK
| | - Caroline Se Homer
- Maternal and Child Health Programme, Burnet Institute, Melbourne, VIC, Australia
| | - Deena Gibbons
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London UK
| | - Niamh M Kelly
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, St Thomas' Hospital Campus, King's College London, London UK
| | | | | | - Paul Taylor
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, St Thomas' Hospital Campus, King's College London, London UK
| | - Marleen Temmerman
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya; Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Cavallaro FL, Pembe AB, Campbell O, Hanson C, Tripathi V, Wong KL, Radovich E, Benova L. Caesarean section provision and readiness in Tanzania: analysis of cross-sectional surveys of women and health facilities over time. BMJ Open 2018; 8:e024216. [PMID: 30287614 PMCID: PMC6173245 DOI: 10.1136/bmjopen-2018-024216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To describe trends in caesarean sections and facilities performing caesareans over time in Tanzania and examine the readiness of such facilities in terms of infrastructure, equipment and staffing. DESIGN Nationally representative, repeated cross-sectional surveys of women and health facilities. SETTING Tanzania. PARTICIPANTS Women of reproductive age and health facility staff. MAIN OUTCOME MEASURES Population-based caesarean rate, absolute annual number of caesareans, percentage of facilities reporting to perform caesareans and three readiness indicators for safe caesarean care: availability of consistent electricity, 24 hour schedule for caesarean and anaesthesia providers, and availability of all general anaesthesia equipment. RESULTS The caesarean rate in Tanzania increased threefold from 2% in 1996 to 6% in 2015-16, while the total number of births increased by 60%. As a result, the absolute number of caesareans increased almost fivefold to 120 000 caesareans per year. The main mechanism sustaining the increase in caesareans was the doubling of median caesarean volume among public hospitals, from 17 caesareans per month in 2006 to 35 in 2014-15. The number of facilities performing caesareans increased only modestly over the same period. Less than half (43%) of caesareans in Tanzania in 2014-15 were performed in facilities meeting the three readiness indicators. Consistent electricity was widely available, and 24 hour schedules for caesarean and (less systematically) anaesthesia providers were observed in most facilities; however, the availability of all general anaesthesia equipment was the least commonly reported indicator, present in only 44% of all facilities (34% of public hospitals). CONCLUSIONS Given the rising trend in numbers of caesareans, urgent improvements in the availability of general anaesthesia equipment and trained anaesthesia staff should be made to ensure the safety of caesareans. Initial efforts should focus on improving anaesthesia provision in public and faith-based organisation hospitals, which together perform more than 90% of all caesareans in Tanzania.
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Affiliation(s)
- Francesca L Cavallaro
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Oona Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Kerry Lm Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Radovich
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Mola GDL, Unger HW. Strategies to reduce and maintain low perinatal mortality in resource-poor settings - Findings from a four-decade observational study of birth records from a large public maternity hospital in Papua New Guinea. Aust N Z J Obstet Gynaecol 2018; 59:394-402. [PMID: 30209806 DOI: 10.1111/ajo.12876] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/13/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND In many low- to middle-income countries (LMIC) assisted vaginal birth rates have fallen, while caesarean section (CS) rates have increased, with potentially deleterious consequences for maternal and perinatal mortality. AIMS To review birth mode and perinatal mortality in a large LMIC hospital with strict labour management protocols and expertise in vacuum extraction. MATERIALS AND METHODS We conducted a retrospective observational study at Port Moresby General Hospital in Papua New Guinea. Birth registers from 1977 to 2015 (39 years) were reviewed. Overall and modified (fresh stillbirths and early neonatal deaths ≥500 g) perinatal mortality rates (PMRs) were calculated by birthweight/birth mode. RESULTS There were 365 056 births (5215 in 1977; 14 927 in 2015), of which 14 179 (3.9%) were vacuum extractions, 609 (0.2%) forceps births and 14 747 (4.4%) CS (increase from 2% to 5%). The failure rate of vacuum extraction was 2.5% (range 0.5-5.4%). Symphysiotomy was employed for 184 births. From 1989 to 2015, the modified mean PMR for babies ≥2500 g was 8.1/1000 births (range 5.6-12.1; 6.9 in 2015), 9.1/1000 for babies ≥1500 g (7.3-14.8; 9.1 in 2015) and 7.5/1000 (0-21.7; 9.0 in 2015) for vacuum extractions (98% were ≥2500 g). The overall PMR for these years was 29.7/1000 births. CONCLUSIONS In an LMIC with rapidly increasing birth numbers a comparatively low PMR can be achieved while maintaining low CS rates. This may be in part accomplished through strict use of second-stage protocols, perinatal audit, and supportive training that promotes judicious and proficient use of vacuum extraction and CS.
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Affiliation(s)
- Glen D L Mola
- Obstetrics and Gynaecology, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea.,Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - Holger W Unger
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Australia.,Department of Obstetrics and Gynaecology, Victoria Hospital, Kirkcaldy, UK
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Kamala BA, Kidanto HL, Wangwe PJ, Dalen I, Mduma ER, Perlman JM, Ersdal HL. Intrapartum fetal heart rate monitoring using a handheld Doppler versus Pinard stethoscope: a randomized controlled study in Dar es Salaam. Int J Womens Health 2018; 10:341-348. [PMID: 30022861 PMCID: PMC6042559 DOI: 10.2147/ijwh.s160675] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Fetal stethoscopes are mainly used for intermittent monitoring of fetal heart rate (FHR) during labor in low-income countries, where perinatal mortality is still high. Handheld Dopplers are rarely available and are dependent on batteries or electricity. The objective was to compare the Pinard stethoscope versus a new wind-up handheld Doppler in the detection of abnormal FHR. Materials and methods We conducted a randomized controlled study at Muhimbili National Hospital, Tanzania, from April 2013 to September 2015. Women with gestational age ≥37 weeks, cephalic presentation, normal FHR on admission, and cervical dilatation <7 cm were included. Primary outcome was abnormal FHR detection (<120 or >160 beats/min). Secondary endpoints were time to delivery, mode of delivery, and perinatal outcomes. χ2, Fisher’s exact test, Mann–Whitney test, and logistic regression were conducted. Unadjusted and adjusted odds ratios were calculated with respective 95% confidence interval. Results In total, 2,844 eligible women were assigned to FHR monitoring with Pinard (n=1,423) or Doppler (n=1,421). Abnormal FHRs were more often detected in the Doppler (6.0%) versus the Pinard (3.9%) arm (adjusted odds ratio =1.59, 95% confidence interval: 1.13–2.26, p=0.008). Median (interquartile range) time from abnormal FHR detection to delivery was comparable between Doppler and Pinard, ie, 80 (60,161) and 89 (52,165) minutes, respectively, as was the incidence of cesarean delivery (12.0% versus 12.2%). The incidence of adverse perinatal outcomes (fresh stillbirths, 24-hour neonatal admissions, and deaths) was similar overall; however, among newborns with abnormal FHR delivered vaginally, adverse outcomes were less incident in Doppler (7 of 43 births, 16.3%) than in the Pinard arm (10 of 23 births, 43.5%), p=0.021. Conclusion Intermittent FHR monitoring using Doppler was associated with an increased detection of abnormal FHR compared to Pinard in a low-risk population. Time intervals from abnormal FHR detection to delivery were longer than recommended in both arms. Perinatal outcomes were better among vaginally delivered newborns with detected abnormal FHR in the Doppler arm.
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Affiliation(s)
- Benjamin A Kamala
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway, .,Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania,
| | - Hussen L Kidanto
- Department of Research, Stavanger University Hospital, Stavanger, Norway.,School of Medicine, Aga Khan University, Dar es Salaam, Tanzania
| | - Peter J Wangwe
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania, .,Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Ingvild Dalen
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Estomih R Mduma
- Department of Research, Stavanger University Hospital, Stavanger, Norway.,Department of Research, Haydon Lutheran Hospital, Manyara, Tanzania
| | | | - Hege L Ersdal
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway, .,Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
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Tura AK, Pijpers O, de Man M, Cleveringa M, Koopmans I, Gure T, Stekelenburg J. Analysis of caesarean sections using Robson 10-group classification system in a university hospital in eastern Ethiopia: a cross-sectional study. BMJ Open 2018; 8:e020520. [PMID: 29622577 PMCID: PMC5892782 DOI: 10.1136/bmjopen-2017-020520] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/16/2018] [Accepted: 02/23/2018] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To analyse caesarean section (CS) using Robson 10-group classification system in an Ethiopian university hospital. DESIGN Cross-sectional study. SETTING A university hospital in eastern, Ethiopia. PARTICIPANTS 980 women who underwent CS from January 2016 to April 2017. MAIN OUTCOME Robson groups (1-10-based on gestational age, fetal presentation, number of fetus, onset of labour and history of CS) and indications for CS. RESULTS Robson group 3 (multiparous women with single cephalic full-term pregnancy in spontaneous labour with no history of CS), group 5 (multiparous women with single cephalic full-term pregnancy with history of CS) and group 1 (single cephalic nulliparous women full-term pregnancy in spontaneous labour) were the major contributors to the overall CS at 21.4%, 21.1% and 19.3%, respectively. The three major indications for CS were fetal compromise (mainly fetal distress), obstructed labour (mainly cephalopelvic disproportion) and previous CS. CONCLUSION Robson groups 3, 5 and 1 were the major contributors to the overall CS rate. Fetal compromise, obstructed labour and previous CS were the underlying indications for performing CS. Further study is required to assess the appropriateness of the indications and to reduce CS among the low-risk groups (groups 1 and 3).
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Affiliation(s)
- Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Olga Pijpers
- Faculty of Medical Sciences, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Myrna de Man
- Faculty of Medical Sciences, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Myrthe Cleveringa
- Faculty of Medical Sciences, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Ingeborg Koopmans
- Faculty of Medical Sciences, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Tadesse Gure
- Department of Obstetrics and Gynaecology, Hiwot Fana Specialized University Hospital, Harar, Ethiopia
- Department of Obstetrics and Gynaecology, Haramaya University College of Health and Medical Sciences, Harar, Ethiopia
| | - Jelle Stekelenburg
- Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, The Netherlands
- Department of Global Health, Health Sciences, University Medical Centre Groningen, Groningen, The Netherlands
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Solnes Miltenburg A, Kiritta RF, Meguid T, Sundby J. Quality of care during childbirth in Tanzania: identification of areas that need improvement. Reprod Health 2018; 15:14. [PMID: 29374486 PMCID: PMC5787311 DOI: 10.1186/s12978-018-0463-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Making use of good, evidence based routines, for management of normal childbirth is essential to ensure quality of care and prevent, identify and manage complications if they occur. Two essential routine care interventions as defined by the World Health Organization are the use of the Partograph and Active Management of the Third Stage of Labour. Both interventions have been evaluated for their ability to assist health providers to detect and deal with complications. There is however little research about the quality of such interventions for routine care. Qualitative studies can help to understand how such complex interventions are implemented. This paper reports on findings from an observation study on maternity wards in Tanzania. METHODS The study took place in the Lake Zone in Tanzania. Between 2014 and 2016 the first author observed and participated in the care for women on maternity wards in four rural and semi-urban health facilities. The data is a result of approximately 1300 hours of observations, systematically recorded primarily in observation notes and notes of informal conversations with health providers, women and their families. Detailed description of care processes were analysed using an ethnographic analysis approach focused on the sequential relationship of the 'stages of labour'. Themes were identified through identification of recurrent patterns. RESULTS Three themes were identified: 1) Women's movement between rooms during birth, 2) health providers' assumptions and hope for a 'normal' birth, 3) fear of poor outcomes that stimulates intervention during birth. Women move between different rooms during childbirth which influences the care they receive. Few women were monitored during their first stage of labour. Routine birth monitoring appeared absent due to health providers 'assumptions and hope for good outcomes. This was rooted in a general belief that most women eventually give birth without problems and the partograph did not correspond with health providers' experience of the birth process. Contextual circumstances also limited health worker ability to act in case of complications. At the same time, fear for being held personally responsible for outcomes triggered active intervention in second stage of labour, even if there was no indication to intervene. CONCLUSIONS Insufficient monitoring leads to poor preparedness of health providers both for normal birth and in case of complications. As a result both underuse and overuse of interventions contribute to poor quality of care. Risk and complication management have for many years been prioritized at the expense of routine care for all women. Complex evaluations are needed to understand the current implementation gaps and find ways for improving quality of care for all women.
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Affiliation(s)
- Andrea Solnes Miltenburg
- Institute of Health and Society, Department of Community Medicine and Global Health, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Richard Forget Kiritta
- Department of Obstetrics and Gynaecology, Sekotoure Regional Referral Hospital, Mwanza, Mwanza Region Tanzania
| | - Tarek Meguid
- Department of Obstetrics & Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - Johanne Sundby
- Institute of Health and Society, Department of Community Medicine and Global Health, Faculty of Medicine, University of Oslo, Oslo, Norway
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Glasziou P, Straus S, Brownlee S, Trevena L, Dans L, Guyatt G, Elshaug AG, Janett R, Saini V. Evidence for underuse of effective medical services around the world. Lancet 2017; 390:169-177. [PMID: 28077232 DOI: 10.1016/s0140-6736(16)30946-1] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Underuse-the failure to use effective and affordable medical interventions-is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.
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Affiliation(s)
- Paul Glasziou
- Centre for Research in Evidence-Based Practice, Bond University, Robina, QLD, Australia.
| | - Sharon Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Lyndal Trevena
- Discipline of General Practice, School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Leonila Dans
- University of the Philippines Manila, Manila, Philippines
| | - Gordon Guyatt
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Ontario, ON, Canada
| | - Adam G Elshaug
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Robert Janett
- Harvard Clinical and Translational Science Center, Boston, MA, USA
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Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. Lancet 2017; 390:156-168. [PMID: 28077234 PMCID: PMC5708862 DOI: 10.1016/s0140-6736(16)32585-5] [Citation(s) in RCA: 535] [Impact Index Per Article: 76.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Affiliation(s)
- Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
| | - Kalipso Chalkidou
- Institute for Global Health Innovation, Imperial College, London, UK
| | - Jenny Doust
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul Glasziou
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Iona Heath
- Royal College of General Practitioners, London, UK
| | | | | | - Divya Srivastava
- LSE Health, London School of Economics and Political Science, London, UK
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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Mgaya A, Hinju J, Kidanto H. Is time of birth a predictor of adverse perinatal outcome? A hospital-based cross-sectional study in a low-resource setting, Tanzania. BMC Pregnancy Childbirth 2017; 17:184. [PMID: 28606111 PMCID: PMC5469024 DOI: 10.1186/s12884-017-1358-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 05/26/2017] [Indexed: 12/25/2022] Open
Abstract
Background Inconsistent evidence of a higher risk of adverse perinatal outcomes during off-hours compared to office hours necessitated a search for clear evidence of an association between time of birth and adverse perinatal outcomes. Methods A cross-sectional study conducted at a tertiary referral hospital compared perinatal outcomes across three working shifts over 24 h. A checklist and a questionnaire were used to record parturients’ socio-demographic and obstetric characteristics, mode of delivery and perinatal outcomes, including 5th minute Apgar score, and early neonatal mortality. Risks of adverse outcomes included maternal age, parity, referral status and mode of delivery, and were assessed for their association with time of delivery and prevalence of fresh stillbirth as a proxy for poor perinatal outcome at a significance level of p = 0.05. Results Off-hour deliveries were nearly twice as likely to occur during the night shift (odds ratio (OR), 1.62; 95% confidence interval (CI), 1.50–1.72), but were unlikely during the evening shift (OR, 0.58; 95% CI, 0.45–0.71) (all p < 0.001). Neonatal distress (O.R, 1.48, 95% CI; 1.07–2.04, p = 0.02), early neonatal deaths (OR, 1.70; 95% CI, 1.07–2.72, p = 0.03) and fresh stillbirths (OR, 1.95; 95% CI, 1.31–2.90, p = 0.001) were more significantly associated with deliveries occurring during night shifts compared to evening and morning shifts. However, fresh stillbirths occurring during the night shift were independently associated with antenatal admission from clinics or wards, referral from another hospital, and abnormal breech delivery (OR 1.9; 95% CI, 1.3–2.9, p = 0.001, for fresh stillbirths; OR, 5.0; 95% CI 1.7–8.3, p < 0.001, for antenatal admission; OR, 95% CI, 1.1–2.9, p < 0.001, for referral form another hospital; and OR 1.6; 95% CI 1.02–2.6, p = 0.004, for abnormal breech deliveries). Conclusion Off-hours deliveries, particularly during the night shift, were significantly associated with higher proportions of adverse perinatal outcomes, including low Apgar score, early neonatal death and fresh stillbirth, compared to morning and evening shifts. Labour room admissions from antenatal wards, referrals from another hospital and abnormal breech delivery were independent risk factors for poor perinatal outcome, particularly fresh stillbirths.
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Affiliation(s)
- Andrew Mgaya
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania. .,Department of Women's and Children's Health, International Maternal and Child Health, Academic Hospital, Uppsala, Sweden.
| | - Januarius Hinju
- Department of Obstetrics and Gynaecology, Benjamin Mkapa referral Hospital, Dodoma, Tanzania
| | - Hussein Kidanto
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania.,Department of Women's and Children's Health, International Maternal and Child Health, Academic Hospital, Uppsala, Sweden.,Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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46
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Rate of and factors associated with indications for cesarean deliveries: Results of a national review in Burkina Faso. Int J Gynaecol Obstet 2017; 135 Suppl 1:S51-S57. [PMID: 27836085 DOI: 10.1016/j.ijgo.2016.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the prevalence of cesarean deliveries in Burkina Faso, analyze the indications for them and the outcomes, and identify factors associated with non-absolute maternal indications for the procedure, as opposed to major obstetric interventions performed to save a woman's life. METHODS In a cross-sectional study, we selected and analyzed cesarean deliveries among those most recently performed between May 2009 and April 2010 in all facilities in Burkina Faso. To identify the factors associated with non-absolute maternal indications, we used generalized estimating equations to take into account the clustering of data at the hospital level. RESULTS The proportion of births by cesarean delivery was 1.5%, with regional variations ranging from 0.8% to 4.5%. They were performed mainly for absolute maternal indications (54.8%). Cesarean deliveries for non-absolute maternal indications were statistically more frequent in private hospitals (OR 2.2; 95% CI, 1.2-4.0), among women in urban areas (OR 1.6; 95% CI, 1.0-2.4), during scheduled cesareans, and in the absence of use of the partogram. CONCLUSION This study confirms the small proportion of cesarean deliveries in Burkina, the disparity between urban and rural areas, and the relative preponderance of absolute maternal indications for cesarean delivery.
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47
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Corso E, Hind D, Beever D, Fuller G, Wilson MJ, Wrench IJ, Chambers D. Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews. BMC Pregnancy Childbirth 2017; 17:91. [PMID: 28320342 PMCID: PMC5359888 DOI: 10.1186/s12884-017-1265-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 02/28/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting. METHODS Pathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS). RESULTS Five clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate. CONCLUSIONS Further research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.
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Affiliation(s)
- Ellena Corso
- School of Medicine and Dentistry, University of Sheffield, Sheffield, UK
| | - Daniel Hind
- Clinical Trials Research Unit, Regent Court, 30 Regent St, Sheffield, S1 4DA UK
| | - Daniel Beever
- Clinical Trials Research Unit, Regent Court, 30 Regent St, Sheffield, S1 4DA UK
| | - Gordon Fuller
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield, S1 4DA UK
| | - Matthew J. Wilson
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield, S1 4DA UK
| | - Ian J. Wrench
- Sheffield Teaching Hospitals Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF UK
| | - Duncan Chambers
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield, S1 4DA UK
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Marino R, Capriglione S, Morosetti G, Di Angelo Antonio S, Miranda A, Pazzola M, Lopez S, Patrizi L, Angioli R, Stella P. May intraperitoneal irrigation with Betadine improve cesarean delivery outcomes? Results of a 6 years’ single centre experience. J Matern Fetal Neonatal Med 2017; 31:670-676. [DOI: 10.1080/14767058.2017.1293036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Riccardo Marino
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, San Camillo-Forlanini Hospital, Rome, Italy
| | - Stella Capriglione
- Department of Obstetrics and Gynaecology Campus Bio-Medico, University of Rome, Rome, Italy
| | - Giulia Morosetti
- Department of Biomedicine and Prevention, Section of Gynecology and Obstetrics, University of Rome Tor Vergata, Rome, Italy
| | - Silvia Di Angelo Antonio
- Department of Biomedicine and Prevention, Section of Gynecology and Obstetrics, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Miranda
- Department of Obstetrics and Gynaecology Campus Bio-Medico, University of Rome, Rome, Italy
| | - Marta Pazzola
- Department of Biomedicine and Prevention, Section of Gynecology and Obstetrics, University of Rome Tor Vergata, Rome, Italy
| | - Salvatore Lopez
- Department of Obstetrics and Gynaecology Campus Bio-Medico, University of Rome, Rome, Italy
| | - Lodovico Patrizi
- Department of Biomedicine and Prevention, Section of Gynecology and Obstetrics, University of Rome Tor Vergata, Rome, Italy
| | - Roberto Angioli
- Department of Obstetrics and Gynaecology Campus Bio-Medico, University of Rome, Rome, Italy
| | - Paolo Stella
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, San Camillo-Forlanini Hospital, Rome, Italy
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Mgaya AH, Kidanto HL, Nystrom L, Essén B. Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania. PLoS One 2016; 11:e0166619. [PMID: 27893765 PMCID: PMC5125608 DOI: 10.1371/journal.pone.0166619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 11/01/2016] [Indexed: 11/28/2022] Open
Abstract
Objective In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting. Methods A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit. Results Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01). Conclusion A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.
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Affiliation(s)
- Andrew H. Mgaya
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Department of Women’s and Children’s Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Hussein L. Kidanto
- Department of Women’s and Children’s Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden
- Reproductive and Child Health section, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Lennarth Nystrom
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Birgitta Essén
- Department of Women’s and Children’s Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden
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50
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Maaløe N, Housseine N, Bygbjerg IC, Meguid T, Khamis RS, Mohamed AG, Nielsen BB, van Roosmalen J. Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study. BMC Pregnancy Childbirth 2016; 16:351. [PMID: 27832753 PMCID: PMC5103376 DOI: 10.1186/s12884-016-1142-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/01/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital. METHODS A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249). RESULTS The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital's registers. The majority of singletons had birthweight ≥2000 g (n = 139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75-315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06-3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68-5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70-12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect. CONCLUSIONS Intrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities. TRIAL REGISTRATION This is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Natasha Housseine
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Tarek Meguid
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
- School of Health & Medical Sciences, State University of Zanzibar, P.O.Box:146, Zanzibar, Tanzania
| | | | | | - Birgitte Bruun Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Jos van Roosmalen
- Athena Institute, VU University of Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands
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