Evidence-based intrapartum practice and its associated factors at a tertiary teaching hospital in the Philippines, a descriptive mixed-methods study

Evidence-based intrapartum care practice and associated factors among obstetrics workers in Ethiopia, systematic review and meta-analysis

Background

Evidence-based practice is defined as using the best available research and clinical evidence by incorporating patients' values and preferences for their health needs. The use of evidence-based intrapartum care practices is an essential tool to improve the quality of obstetrics care.

Objective

The primary objective of this study was to determine the prevalence of evidence-based intrapartum care and associated factors among obstetrics care providers in Ethiopia.

Method

Important articles were retrieved from universally accepted and used databases, including Cochran, PubMed, HINARI, Google Scholar, Web of Science, African OnLine, and repositories of Ethiopian Universities. We extracted articles by using a standard JOANNA Briggs Institute data extraction sheet. To determine the existence of heterogeneity in studies, I 2 statistics and Cochran Q tests were used. The publication bias of the included studies was checked using Egger's test and a Funnel plot.

Result

A total of 2035 obstetrics care providers were involved in this systematic review and meta-analysis. The estimated overall rate of evidence-based intrapartum care practice in Ethiopia was 54.45% (95% CI: 43.06, 65.83); I 2 = 96.6%, p < 0.001). The studies with a sample size greater than 300 count for 47.25% (95% CI: 36.14, 65.83). Whereas obstetrics care providers have a decent knowledge of intrapartum care evidence 3.31 times, a positive attitude toward evidence 3.34 times, training 2.21 times, and work experience ⩾5 years 3.31 times associated with the practice of evidence-based intrapartum care.

Conclusion

The overall practice of evidence-based intrapartum care among obstetrics workers in Ethiopia is estimated to be low. Therefore, there should be a focused effort on training and disseminating protocols and guidelines to enhance knowledge and foster a positive attitude among obstetrics care providers. Additionally, the Ethiopian government should prioritize the implementation of the 2021 to 2025 National Health Equity Strategic Plan to achieve its objective of improving the quality of health services.

Observation of non-recommended (harmful) intrapartum practices among obstetric care providers in public hospitals in southern Ethiopia, 2023

The majority of developing countries do not follow the WHO's emphasis on replacing harmful and ineffective traditional practices with evidence-based clinical treatment. In these countries, harmful or ineffective practices are routinely used as part of routine care during labor and delivery, while beneficial procedures are not used for the majority of laboring mothers. However, it is critical to use evidence-based practices while giving therapy since they improve care quality, save costs, increase patient and family happiness, and promote professional progress. To assess the magnitude of non-recommended (harmful) intrapartum practices among obstetric care providers in public hospitals in southern Ethiopia, 2023. An institution-based cross-sectional study was conducted from January 30, 2023, to February 30, 2023, in public hospitals in the Gamo and Gofa zones. An observational checklist and a self-administered questionnaire were used to gather data. Using odds ratio of 95% C, bivariate and multivariable logistic regression was used to discover factors related with the outcome variable during data analysis using SPSS version 27. A P-value of less than 0.05 and I were regarded as statistically significant. The magnitude of harmful intrapartum practice was 60.6% (95% CI: 53.25-68.5). Lack of internet access (AOR = 10.1, 95% CI: 4.93-21.1), a few years of work experience (AOR = 6.21, 95% CI: 3.1-12.5), and not being trained on evidence-based intrapartum practices (AOR = 4.01, 95% CI: 1.94-7.95) were statistically significant with harmful intrapartum practices. Evidence-based practice can be improved by promptly providing obstetric care providers with ongoing training and standards for intrapartum care.

Evidence-based intrapartum care during vaginal births: Direct observations in a tertiary care hospital in Central Sri Lanka

Background

Evidence-based practice (EBP) is an effective approach to improve maternal and newborn outcomes at birth.

Objective

This study aimed to assess the current intrapartum practices of a tertiary care hospital in Central Province, Sri Lanka, during vaginal births. The benchmark for this assessment was the World Health Organisation's (WHO) recommendations on intrapartum care for a positive childbirth experience.

Methods

An observational study was conducted at the delivery room of Teaching Hospital, Peradeniya with the participation of 196 labouring women who were selected using systematic random sampling. A non-participant observation checklist covering labour room admission procedures, management of the first, second, and third stages of labour, and immediate care of the newborn and postpartum mother was used for the data collection. The care interventions implemented throughout labour and childbirth were observed and recorded. The data analysis was done using SPSS version 22.

Results

WHO-recommended practices such as providing privacy (33.2%), offering oral fluids (39.3%), and opioids for pain relief (48.5%) were found to be infrequent. Encouraging correct pushing techniques (77.6%), early breastfeeding (83.2%), regular assessment of vaginal bleeding (91.3%), skin-to-skin contact (93.4%), and using prophylactic uterotonics (100.0%) were found to be frequent. However, labour companionship, use of upright positions during labour, women's choice of birth position, and use of manual or relaxation techniques for pain relief were not observed in hospital intrapartum care.

Conclusion

The findings of the study indicate that additional attention and monitoring are required to align the current intrapartum care practices with the WHO recommendations. Moreover, the adoption of evidence-based intrapartum care should be encouraged by conveying the standard evidence-based intrapartum care guidelines to the grassroots level healthcare workers to avoid intrapartum interventions.

Is an episiotomy always necessary during an operative vaginal delivery with vacuum? A longitudinal study

Objective: The use of episiotomy during operative vaginal birth (OVB) is rather debated among operators and in literature. It is also important to evaluate the indications for which episiotomy is performed. In fact, the consequences of an episiotomy can be invalidating for patients with long-lasting results. The aim of this study is the evaluation of the role of episiotomy during OVB with the vacuum extractor and its correlation with Obstetric Anal Sphincter Injuries (OASIs).Methods: On of 9165 vaginal births, a total of 498 OVB (5.4%) were enrolled in a longitudinal prospective observational study. The incidence of OASIs was evaluated in our population after OVB performed with the vacuum extractor, during which the execution of episiotomy was performed indicated by clinician in charge.Results: OASIs occurred in 4% of the patients (n = 20). Episiotomy was performed in 39% of them (n = 181). OASIs incidence was 6% (n = 17) in the No Episiotomy and 1.8% (n = 3) in Episiotomy group (p<.001). Performance of episiotomy during OVB determined a protective effect against OASIs (p = 0.025 in full cohort and p = 0.013 in the primiparous group). An expulsive phase under one hour was an almost significant protective factor (p = 0.052).Conclusions: The use of episiotomy during OVB was associated with much lower OASIs rates in nulliparous women with a vacuum extraction; OR 0.23 (CI 95% 0.07-0.81) p = 0.037 in nulliparous women and the number necessary to treat was 18 among nulliparous women to prevent 1 OASIs. A further risk factor that emerged from the analysis is a prolonged expulsive period, whereas fundal pressure does not seem to have a statistically significant influence.

Baseline Assessment of Evidence-Based Intrapartum Care Practices in Medical Schools in 3 States in India: A Mixed-Methods Study

INTRODUCTION

Implementation research with pre- and post-comparison was planned to improve the quality of evidence-based intrapartum care services in Indian medical schools. We present the baseline study results to assess the status of adherence to intrapartum evidence-based practices (IP-EBP) in study schools in 3 states in India and the perception of the faculty.

METHODS

A concurrent mixed-methods approach was used to conduct the baseline assessment in 9 medical schools in Rajasthan, Gujarat, and Union Territory from October 2018 to June 2019. IP-EBP among pregnant women in uncomplicated first (n=135), second (n=120), and third stage (n=120) of labor were observed using a predesigned, pretested checklist quantitatively. We conducted in-depth interviews with 33 obstetrics and gynecology faculty to understand their perceptions of intrapartum practices. Quantitative data were analyzed using SPSS (version 22). COM-B (Capability, Opportunity, and Motivation Behavior) model was used to understand the behaviors, and thematic analysis was done for the qualitative data.

FINDINGS

Unindicated augmentation of labor was done in 64.4%, fundal pressure applied in 50.8%, episiotomy done in 58.3%, and delivery in lithotomy position was performed in 86.7% of women in labor.

CONCLUSIONS

Intrapartum practices that are not recommended were routinely practiced in the study medical schools due to a lack of staff awareness of evidence-based practices and incorrect beliefs about their impact.

Effect of Hypnobirthing Training on Fear, Pain, Satisfaction Related to Birth, and Birth Outcomes: A Randomized Controlled Trial

We aimed to determine the effect of Hypnobirthing training on fear of childbirth (FOC), birth pain, birth satisfaction and birth outcomes. This randomized controlled trial study was conducted with 80 nulliparous pregnant who were divided into two groups (experimental group n = 40 and control n = 40) in a maternity hospital. The couples received the training in groups(4 weeks, once a week, 3-hour, group session). The mean score of hypnobirthing group for the whole Wijma Birth Expectancy/Experience Scale was significantly lower than that of the routine care group (p < .001).In the latent, active, and transitional phases of labor, the Visual Analog Scale (VAS)scores of the experimental groups were found to be significantly lower than those of the control group (p < .001).The experimental group's rates of birth intervention were significantly lower and their deliveries period were shorter, than those that of the routine control group (p < .001).In addition, the vaginal delivery rates (p = .037)and the scores for the Birth Satisfaction Scale-Revised (BSS-R) were also found to be higher than those of the control group (p < .001).

Coexistence and prevalence of obstetric interventions: an analysis based on the grade of membership

BACKGROUND

Obstetric interventions performed during delivery do not reflect improvements in obstetric care. Several practices routinely performed during childbirth, without any scientific evidence or basis - such as Kristeller maneuver, routine episiotomy, and movement or feeding restriction - reflect a disrespectful assistance reality that, unfortunately, remains in place in Brazil. The aims of the current study are to assess the coexistence and prevalence of obstetric interventions in maternity hospitals in Belo Horizonte City, based on the Grade of Membership (GoM) method, as well as to investigate sociodemographic and obstetric factors associated with coexistence profiles generated by it.

METHODS

Observational study, based on a cross-sectional design, carried out with data deriving from the study "Nascer em Belo Horizonte: Inquérito sobre o Parto e Nascimento" (Born in Belo Horizonte: Survey on Childbirth and Birth). The herein investigated interventions comprised practices that are clearly useful and should be encouraged; practices that are clearly harmful or ineffective and should be eliminated; and practices that are inappropriately used, in contrast to the ones recommended by the World Health Organization. The analyzed interventions comprised: providing food to parturient women, allowing them to have freedom to move, use of partogram, adopting non-pharmacological methods for pain relief, enema, perineal shaving, lying patients down for delivery, Kristeller maneuver, amniotomy, oxytocin infusion, analgesia and episiotomy. The current study has used GoM to identify the coexistence of the adopted obstetric interventions. Variables such as age, schooling, skin color, primigravida, place-of-delivery financing, number of prenatal consultations, gestational age at delivery, presence of obstetric nurse at delivery time, paid work and presence of companion during delivery were taken into consideration at the time to build patients' profile.

RESULTS

Results have highlighted two antagonistic obstetric profiles, namely: profile 1 comprised parturient women who were offered diet, freedom to move, use of partogram, using non-pharmacological methods for pain relief, giving birth in lying position, patients who were not subjected to Kristeller maneuver, episiotomy or amniotomy, women did not receive oxytocin infusion, and analgesia using. Profile 2, in its turn, comprised parturient women who were not offered diet, who were not allowed to have freedom to move, as well as who did not use the partograph or who were subjected to non-pharmacological methods for pain relief. They were subjected to enema, perineal shaving, Kristeller maneuver, amniotomy and oxytocin infusion. In addition, they underwent analgesia and episiotomy. This outcome emphasizes the persistence of an obstetric care model that is not based on scientific evidence. Based on the analysis of factors that influenced the coexistence of obstetric interventions, the presence of obstetric nurses in the healthcare practice has reduced the likelihood of parturient women to belong to profile 2. In addition, childbirth events that took place in public institutions have reduced the likelihood of parturient women to belong to profile 2.

CONCLUSION(S)

Based on the analysis of factors that influenced the coexistence of obstetric interventions, financing the hospital for childbirth has increased the likelihood of parturient women to belong to profile 2. However, the likelihood of parturient women to belong to profile 2 has decreased when hospitals had an active obstetric nurse at the delivery room. The current study has contributed to discussions about obstetric interventions, as well as to improve childbirth assistance models. In addition, it has emphasized the need of developing strategies focused on adherence to, and implementation of, assistance models based on scientific evidence.

Perspectives of skilled birth attendants and pregnant women regarding episiotomy: a quantitative approach

Background

The World Health Organization recommended less than 10% episiotomy rate for Skilled Birth Attendants (SBAs) and hospitals in 1996. More than two decades afterwards, some health facilities are still grappling with meeting the set target.

Objectives

This study assessed the perspectives of SBAs and pregnant women regarding episiotomy in a Nigerian university teaching hospital.

Methods

A cross-sectional design was employed. Census sampling was used to select 19 SBAS and 973 vaginal birth records from 2019, while consecutive sampling technique was used to enrol 134 consenting pregnant women obtaining antenatal services in the facility. Data was collected using a three part instrument involving a data extraction sheet, episiotomy practice questionnaire for SBAs, and feelings about episiotomy questionnaire for pregnant women. Assembled data were summarised with descriptive statistics.

Results

The episiotomy rate was 345(35.5%). About 266 (77.1%) of first time mothers (primips) and 79(22.9%) of nonfirst time mothers (multips) received episiotomy. Ten (52.6%) of the SBAs were unsure of any evidence supporting routine episiotomy. All the 19(100%) SBAs reported that there was no existing facility-based policy regarding routine episiotomy. Seventy five (56%) of the pregnant women reported feeling generally bad about episiotomy. One hundred and one (82.3%) of them hinted that they will not feel satisfied if they were given episiotomy with the reason that it ensures quick vaginal birth.

Conclusion

The rate of episiotomy was higher than global recommended standards and primips are disproportionately affected. If organised by professional societies, more scientific conferences on limiting episiotomy might remedy this situation.

Knowledge on intrapartum care practices among skilled birth attendants in Cambodia-a cross-sectional study

Background

Delivery is a critical moment for pregnant women and babies, and careful monitoring is essential throughout the delivery process. The partograph is a useful tool for monitoring and assessing labour progress as well as maternal and foetal conditions; however, it is often used inaccurately or inappropriately. A gap between practices and evidence-based guidelines has been reported in Cambodia, perhaps due to a lack of evidence-based knowledge in maternity care. This study aims to address to what extent skilled birth attendants in the first-line health services in Cambodia have knowledge on the management of normal delivery, and what factors are associated with their level of knowledge.

Methods

Midwives and nurses were recruited working in maternity in first-line public health facilities in Phnom Penh municipality, Kampong Cham and Svay Rieng provinces. Two self-administered questionnaires were applied. The first consisted of three sections with questions on monitoring aspects of the partograph: progress of labour, foetal, and maternal conditions. The second consisted of questions on diagnostic criteria, normal ranges, and standard intervals of monitoring during labour. A multiple linear regression analysis was performed to identify relationships between characteristics of the participants and the questionnaire scores.

Results

Of 542 eligible midwives and nurses, 523 (96%) participated. The overall mean score was 58%. Only 3% got scores of more than 90%. Multivariate analysis revealed that ‘Kampong Cham province’, ‘younger age’, and ‘higher qualification’ were significantly associated with higher scores. Previous training experience was not associated with the score. Substantial proportions of misclassification of monitoring items during labour were found; for example, 61% answered uterine contraction as a foetal condition, and 44% answered foetal head descent and 26% answered foetal heart rate as a maternal condition.

Conclusion

This study found that knowledge was low on delivery management among skilled birth attendants. Previous training experience did not influence the knowledge level. A lack of understanding of physiology and anatomy was implied. Further experimental approaches should be attempted to improve the knowledge and quality of maternity services in Cambodia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01166-z.

Pregnancy and childbirth are natural phenomena, but sometimes have risk for mothers and babies. Therefore, childbirth should be carefully and continuously monitored by the health care professional. The ‘partograph’ is a useful tool that defines three monitoring aspects of the delivery progress, and conditions of the mother and intrauterine baby. However, it is often used inaccurately or inappropriately in low- and middle-income countries. We hypothesised that health professionals who assist childbirth cannot effectively monitor delivery conditions because their knowledge is insufficient. Therefore, we evaluated the knowledge on monitoring the process of childbirth and explored factors which affect the level of knowledge among health care providers in Cambodia.

Midwives and nurses were targeted in this study who deal with normal deliveries in the capital city and two provinces. The questionnaire was designed to evaluate if their knowledge on three monitoring aspects is accurate.

Of 542 eligible personnel, 523 (96%) participated. The mean score was 58%. Only 3% got scores of more than 90%. According to the statistical analysis, ‘working in Kampong Cham province’, ‘younger age’, and ‘higher qualification’ were significantly associated with higher scores. Previous training experience was not associated with the score.

This study found that basic knowledge was low on delivery management among health care providers. We suspect that a deficiency of basic medical knowledge, such as physiology and anatomy, causes the lack of knowledge on the childbirth process. Further intervention should be attempted to improve the knowledge and quality of maternity services in Cambodia.

The prevalence of uterine fundal pressure during the second stage of labour for women giving birth in health facilities: a systematic review and meta-analysis

BACKGROUND

Uterine fundal pressure involves a birth attendant pushing on the woman's uterine fundus to assist vaginal birth. It is used in some clinical settings, though guidelines recommend against it. This systematic review aimed to determine the prevalence of uterine fundal pressure during the second stage of labour for women giving birth vaginally at health facilities.

METHODS

The population of interest were women who experienced labour in a health facility and in whom vaginal birth was anticipated. The primary outcome was the use of fundal pressure during second stage of labour. MEDLINE, EMBASE, CINAHL and Global Index Medicus databases were searched for eligible studies published from 1 January 2000 onwards. Meta-analysis was conducted to determine a pooled prevalence, with subgroup analyses to explore heterogeneity.

RESULTS

Eighty data sets from 76 studies (n = 898,544 women) were included, reporting data from 22 countries. The prevalence of fundal pressure ranged from 0.6% to 69.2% between studies, with a pooled prevalence of 23.2% (95% CI 19.4-27.0, I2 = 99.97%). There were significant differences in prevalence between country income level (p < 0.001, prevalence highest in lower-middle income countries) and method of measuring use of fundal pressure (p = 0.001, prevalence highest in studies that measured fundal pressure based on women's self-report).

CONCLUSIONS

The use of uterine fundal pressure on women during vaginal birth in health facilities is widespread. Efforts to prevent this potentially unnecessary and harmful practice are needed.

Situation of labour room documentation at secondary level public health facilities of Cuttack district, Odisha, India - A SWOT analysis

Background:

Poor documentation practices in labour rooms have been a challenge especially in resource limited countries. This hinders the efforts towards improving quality of maternal healthcare services. Little effort has been made on this regard in many countries including India. SWOT analysis on labour room documentation would be the first step in understanding the situation, barriers and to formulate strategies for improvement.

Materials and Methods:

Facility based cross-sectional study was carried out in five secondary health facilities of Cuttack district, Odisha, India. A qualitative method using in-depth interviews among 26 healthcare providers was adopted for data collection and inductive content analysis approach for analysis. Strategies like pioneering, positive, conservative and resistive were formulated under each of the three major components identified.

Results:

Three major components emerged were i) Adherence and completeness of labour room records and reports, ii) Status of the monitoring and supervision and iii) Utilization of labour room data. Improving knowledge and skill through training and supportive supervision, adopting computer-based application for data management, better coordination among supervisors and labour room staff, infrastructural strengthening for documentation and its security, making documentation a priority, more accountability would improve the documentation. Ensuring data analysis and interpretation, discussion in review meetings and regular monitoring and supervision will improve performance.

Conclusion:

Ensuring documentation of labour room records, regular quality monitoring and supervision, and analysis and interpretation of data are critical to improve labour room performance. Making it a priority and adopting the strategies will achieve the same, thereby better labour outcome.