Impact of the WHO Safe Childbirth Checklist on safety culture among health workers: A randomized controlled trial in Aceh, Indonesia

The World Health Organization (WHO) developed the Safe Childbirth Checklist (SCC) to increase the application of essential birth practices to ultimately reduce perinatal and maternal deaths. We study the effects of the SCC on health workers safety culture, in the framework of a cluster-randomized controlled trial (16 treatment facilities/16 control facilities). We introduced the SCC in combination with a medium intensity coaching in health facilities which already offered at minimum basic emergency obstetric and newborn care (BEMonC). We assess the effects of using the SCC on 14 outcome variables measuring self-perceived information access, information transmission, frequency of errors, workload and access to resources at the facility level. We apply Ordinary Least Square regressions to identify an Intention to Treat Effect (ITT) and Instrumental Variable regressions to determine a Complier Average Causal Effect (CACE). The results suggest that the treatment significantly improved self-assessed attitudes regarding the probability of calling attention to problems with patient care (ITT 0.6945 standard deviations) and the frequency of errors in times of excessive workload (ITT -0.6318 standard deviations). Moreover, self-assessed resource access increased (ITT 0.6150 standard deviations). The other eleven outcomes were unaffected. The findings suggest that checklists can contribute to an improvement in some dimensions of safety culture among health workers. However, the complier analysis also highlights that achieving adherence remains a key challenge to make checklists effective.

Effects of the World Health Organization Safe Childbirth Checklist on Quality of Care and Birth Outcomes in Aceh, Indonesia: A Cluster-Randomized Clinical Trial

Importance

To address major causes of perinatal and maternal mortality, the World Health Organization developed the Safe Childbirth Checklist (SCC), which to our knowledge has been rigorously evaluated only in combination with high-intensity coaching.

Objective

To evaluate the effect of the SCC with medium-intensity coaching on health care workers' performance of essential birth practices.

Design, Setting, and Participants

This cluster randomized clinical trial without blinding included 32 hospitals and community health centers in the province of Aceh, Indonesia (a medium-resource setting) that met the criterion of providing at least basic emergency obstetric and newborn care. Baseline data were collected from August to October 2016, and outcomes were measured from March to April 2017. Data were analyzed from January 2020 to October 2021.

Interventions

After applying an optimization method, facilities were randomly assigned to the treatment or control group (16 facilities each). The SCC with 11 coaching visits was implemented during a 6-month period.

Main Outcomes and Measures

For the primary outcome, clinical observers documented whether 36 essential birth practices were applied at treatment and control facilities at 1 or more of 4 pause points during the birthing process (admission to the hospital, just before pushing or cesarean delivery, soon after birth, and before hospital discharge). Probability models for binary outcome measures were estimated using ordinary least-squares regressions, complemented by Firth logit and complier average causal effect estimations.

Results

Among the 32 facilities that participated in the trial, a significant increase of up to 41 percentage points was observed in the application of 5 of 36 essential birth practices in the 16 treatment facilities compared with the 16 control facilities, including communication of danger signs at admission (treatment: 136 of 155 births [88%]; control: 79 of 107 births [74%]), measurement of neonatal temperature (treatment: 9 of 31 births [29%]; control: 1 of 20 births [5%]), newborn feeding checks (treatment: 22 of 34 births [65%]; control: 5 of 21 births [24%]), and the rate of communication of danger signs to mothers and birth companions verbally (treatment: 30 of 36 births [83%]; control: 14 of 22 births [64%]) and in a written format (treatment: 3 of 24 births [13%]; control: 0 of 16 births [0%]).

Conclusions and Relevance

In this cluster randomized clinical trial, health facilities that implemented the SCC with medium-intensity coaching had an increased rate of application for 5 of 36 essential birth practices compared with the control facilities. Medium-intensity coaching may not be sufficient to increase uptake of the SCC to a satisfying extent, but it may be worthwhile to assess a redesigned coaching approach prompting long-term behavioral change and, therefore, effectiveness.

Trial Registration

isrctn.org Identifier: ISRCTN11041580.

Healthcare providers' perception of the referral system in maternal care facilities in Aceh, Indonesia: a cross-sectional study

OBJECTIVES

Our study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia.

DESIGN

With a cross-sectional approach, two sets of surveys were administered during September to October 2016 in 32 sampling units of our study. We also collected referral data in the form of the frequency of ingoing and outgoing referral cases per facility.

SETTING

In three districts, Aceh Besar, Banda Aceh and Bireuen, a total of 32 facilities including hospitals, community health centres, and private midwife clinics that met the criteria of providing at least basic emergency obstetric and neonatal care (BEonC) were covered.

PARTICIPANTS

Across the 32 healthcare centres, 149 members of staff (mainly midwives) agreed to participate in our surveys.

PRIMARY AND SECONDARY OUTCOME MEASURES

The first survey consisted of 65 items focusing on organisational measures as well as case numbers for example, patient counts, mortality rate and complications. The second survey with 68 items asked healthcare providers about a range of factors including attitudes towards the referral process in their facility and potential barriers to a well-functioning system in their district.

RESULTS

Overall, mothers'/families' consent as well as the complex administration process were found to be the main barriers (36% and 12%, respectively). Healthcare providers noted that information about other facilities has the biggest room for improvement (37%) rather than transport, timely referral of mothers and babies, or the availability of referral facilities.

CONCLUSIONS

The largest barrier perceived by healthcare providers in our study was noted to be family consent and administrative burden. Moreover, lack of information about the referral system itself and other facilities seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.

Colistin- and carbapenem-resistant Klebsiella oxytoca harboring blaVIM-2 and an insertion in the mgrB gene isolated from blood culture

A carbapenemase-producing colistin-resistant Klebsiella oxytoca isolate was recovered from a blood culture of a female patient without previous report of risk factors to obtain multidrug-resistant Gram-negative bacilli. A combination of biochemical and molecular methods was used to identify the resistance mechanism of this isolate. Carbapenemase production was mediated by Verona integron-encoded metallo-β-lactamase (VIM)-2. Colistin resistance was not due to plasmid- borne mcr-1 gene, but we found an integration of IS5-like sequence in the mgrB gene of K. oxytoca. This gene is known to be an important regulator of the PhoPQ two-component system, and the disruption of this gene is most likely the cause of lipid A modification resulting in colistin resistance of our isolate. To the best of our knowledge this constitutes the first report of a carbapenemase-producing K. oxytoca with colistin resistance, a case that demonstrates the limited treatment options for infections with multidrug-resistant organisms.

The deubiquitinating enzyme Ubp21p of fission yeast stabilizes a mutant form of protein kinase Prp4p

The protein kinase Prp4p of Schizosaccharomyces pombe is involved in control of the formation of active spliceosomes, phosphorylating the spliceosomal component Prp1p. The kinase domain of Prp4p is closely related to cyclin-dependent kinases (CDKs) and mitogen-activated kinases (MAPKs). A mutational analysis of the highly conserved amino acid sequence ALKHP in subdomain XI of this kinase showed that structural features of this sequence are important for the function of the kinase. We identified ubp21 as a high-copy-number suppressor of a mutation in the ALKHP motif. Characterization of this gene revealed that it encodes a deubiquitinating enzyme belonging to the family of ubiquitin-specific processing proteases (Ubps). The results presented in this report are consistent with the notion that the deubiquitinating activity of Ubp21p may be involved in regulating the steady-state levels of proteins including Prp4p.

Fission yeast Prp4p kinase regulates pre-mRNA splicing by phosphorylating a non-SR-splicing factor

We provide evidence that Prp4p kinase activity is required for pre-mRNA splicing in vivo and show that loss of activity impairs G1-S and G2-M progression in the cell cycle. Prp4p interacts genetically with the non-SR (serine/arginine) splicing factors Prp1p and Prp5p. Bacterially produced Prp1p is phosphorylated by Prp4p in vitro. Prp4p and Prp1p also interact in the yeast two-hybrid system. In vivo labelling studies using a strain with a mutant allele of the prp4 gene in the genetic background indicate a change in phosphorylation of the Prp1p protein. These results are consistent with the notion that Prp4p kinase is involved in the control of the formation of active spliceosomes, targeting non-SR splicing factors.

spp42, identified as a classical suppressor of prp4-73, which encodes a kinase involved in pre-mRNA splicing in fission yeast, is a homologue of the splicing factor Prp8p

We have identified two classical extragenic suppressors, spp41 and spp42, of the temperature sensitive (ts) allele prp4-73. The prp4(+) gene of Schizosaccharomyces pombe encodes a protein kinase. Mutations in both suppressor genes suppress the growth and the pre-mRNA splicing defect of prp4-73(ts) at the restrictive temperature (36 degrees ). spp41 and spp42 are synthetically lethal with each other in the presence of prp4-73(ts), indicating a functional relationship between spp41 and spp42. The suppressor genes were mapped on the left arm of chromosome I proximal to the his6 gene. Based on our mapping data we isolated spp42 by screening PCR fragments for functional complementation of the prp4-73(ts) mutant at the restrictive temperature. spp42 encodes a large protein (p275), which is the homologue of Prp8p. This protein has been shown in budding yeast and mammalian cells to be a bona fide pre-mRNA splicing factor. Taken together with other recent genetic and biochemical data, our results suggest that Prp4 kinase plays an important role in the formation of catalytic spliceosomes.

Identification and characterization of srp1, a gene of fission yeast encoding a RNA binding domain and a RS domain typical of SR splicing factors

The SR protein family is involved in constitutive and regulated pre-mRNA splicing and has been found to be evolutionarily conserved in metazoan organisms. In contrast, the genome of the unicellular yeast Saccharomyces cerevisiae does not contain genes encoding typical SR proteins. The mammalian SR proteins consist of one or two characteristic RNA binding domains (RBD), containing the signature sequences RDAEDA and SWQDLKD respectively, and a RS (arginine/serine-rich) domain which gave the family its name. We have now cloned from the fission yeast Schizosaccharomyces pombe the gene srp1. This gene is the first yeast gene encoding a protein with typical features of mammalian SR protein family members. The gene is not essential for growth. We show that overexpression of the RNA binding domain inhibits pre-mRNA splicing and that the highly conserved sequence RDAEDA in the RBD is involved. Overexpression of Srp1 containing mutations in the RS domain also inhibits pre-mRNA splicing activity. Furthermore, we show that overexpression of Srp1 and overexpression of the mammalian SR splicing factor ASF/SF2 suppress the pre-mRNA splicing defect of the temperature-sensitive prp4-73 allele. prp4 encodes a protein kinase involved in pre-mRNA splicing. These findings are consistent with the notion that Srp1 plays a role in the splicing process.

[Estrogenic effects after 14-days administration of 0.06 mg ethinyl estradiol in postmenopausal women]

The effect of a 26 day oestrogen-gestogene sequence therapy on double endometrium thickness, uterus size, blood flow in the uterine blood vessels (pulsatility and resistance index), serum concentration of FSH, LH and SHBG and on vaginal cytology of postmenopausal women was tested double-blind in a placebo-controlled trial. Thirteen postmenopausal women received 0.06 mg ethinyloestradiol (EE2) over 14 days and then a 12 day combination treatment with 0.04 mg EE2 and 0.125 mg levonorgestrel. Eight women received placebo treatment over 26 days. In each group, half the women were less, and half were more than 10 years postmenopausal. The above parameters were unchanged in the placebo group. However, in the verum group, the double endometrium thickness increased from 2 mm to about 6 mm after a 7 day treatment with EE2 and after a further treatment week with EE2, increased another millimeter. There was no obvious difference in the treatment groups between women less than ten years after menopause or more than ten years after menopause. Blood flow in the uterine artery increased significantly (decrease in pulsatility and resistance index by about 50%). Again, there did not seem to be any obvious connection with the menopausal interval. FSH decreased after the first treatment week by about 50% and 65% after the second treatment week. There was no significant decrease in LH. SHBG increased by about a factor of 5. An oestrogen effect could be demonstrated in the vaginal cytology of all cases in the verum group.

A single-dose and 3-month clinical-pharmacokinetic study with a new combination oral contraceptive

The study was performed in 14 young women. The combination oral contraceptive contained 75 microgram gestodene (GSD) and 20 microgram ethinyl estradiol (EE2) per dosage unit. The volunteers received a single dose on day 21 of a treatment-free precycle (PCd21) and, after a washout period of 7 days, used the preparation in a 21 d/7 d schedule for three months. Daily drug serum level profiles were taken on PCd21 and on days 1 and 21 of treatment cycles 1 and 3. In addition, trough drug serum levels were followed every other day during treatment cycles 1 and 3. Serum levels of GSD, EE2, CBG, SHBG and testosterone (T) were determined by means of specifically developed or commercially available RIAs. Pharmacokinetic evaluation was carried out with TOPFIT and parameters were evaluated for differences with the t-test. Main target variables were Cmax, tmax and AUC for EE2, GSD and unbound GSD on day 21, cycle 3 vs. PCd21. EE2 pharmacokinetics were in agreement with a dose of 20 microgram/unit. Single-dose Cmax of 65 pg/ml and AUC of 612 pg h ml(-1) increased by 40-60% during treatment cycles as a result of accumulation EE2 induced basal SHBG (102nmol/L) and CBG (42 microgram/ml) serum levels to about 220 nmol/L and 87 microgram/ml, respectively, at the end of treatment cycles 1 and 3. Serum T levels dropped to 50% of baseline levels during treatment cycles and free T concentrations were reduced by 60-70%. GSD pharmacokinetics at the end of treatment cycles 1 and 3 were different from single-dose pharmacokinetics. Single-dose Cmax of 3.5 ng/ml and AUC 0-24 h of 22 ng h ml(-1) increased to steady-state levels of 8-8.7 ng/ml and 90-106 ng h ml(-1), respectively. The increase in GSD levels under treatment is the result of two parallel processes, i.e. accumulation and enlargement of the specific binding compartment. This was shown by protein-binding experiments, demonstrating an increase in specific (SHBG) binding from 69% to 80% and a reduction in the free fraction of GSD by 40% during treatment. The results of GSD and EE2 pharmacokinetics obtained in the present study confirm previous results with Femodene, when the reduction in the EE2 dose by 10 microgram/d is taken into account.