Evidence-based Obstetric Care Research Articles

1.O. Workshop: Caesarean section in Europe: Are women and babies receiving evidence-based obstetric care?

Abstract Every year in Europe, over 1.5 million women have a caesarean section (CS). The use of this surgical procedure is increasing globally, leading to concerns about a caesarean “epidemic”. While CS is a lifesaving procedure for mothers and babies with complications during pregnancy or labour, national variations in CS rates suggest the absence of standardised indications: in Europe rates vary from lows of 16% (Nordic countries, the Netherlands) to over 40% (Poland, Romania, Greece, Cyprus). Worldwide, the gap between low and high CS countries is even greater. To assess the magnitude of the variations in CS in terms of numbers of women experiencing the procedure in Europe, the Euro-Peristat network calculated that there would be 500,000 fewer CS if all countries had the rates in the lowest CS country. There is uncertainty about what the “optimal” CS rate should be and how this might differ in relation to the health of the childbearing population. CS risk is associated with characteristics of the childbearing population, such as older maternal age, nulliparity, higher body mass index and maternal chronic conditions. The optimal CS rate may also differ depending on the organisation and capacity of the health system. European countries provide a unique context for exploring these questions they have similar standards of living and access to advanced medicine, but differ greatly in the organisation of their health systems and CS practices. In this session, we will present three studies reporting recent data on CS variations and trends in Europe from the Euro-Peristat network to shed light on these questions. The presentations will be followed by a round table discussion about the next steps for evaluating the reasons as well as the health impact of varying practices in order to ensure that European women receive evidence-based obstetric care. Key messages • The persisting variation in the use of caesarean section between European countries raises questions about whether pregnant women and babies are receiving evidence-based care. • Europe provides a unique context for exploring these variations because despite high standards of living and access to medical care, marked differences persist between countries.

Ready to deliver maternal and newborn care? Health providers’ perceptions of their work context in rural Mozambique

ABSTRACTBackground: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence.Objectives: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique.Methods: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach’s α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique.Results: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed.Conclusions: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants’ responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

A mixed-methods study of barriers and facilitators to the implementation of postpartum hemorrhage guidelines in Uganda.

To determine the level of adherence to postpartum hemorrhage clinical guideline recommendations and to explore context-specific barriers and facilitators to evidence-based obstetric care. Using direct observation of deliveries at a Ugandan healthcare facility, a mixed-methods study was conducted between February and March 2014 to document practices related to the active management of the third stage of labor (AMTSL). The degree to which practice concurred with WHO postpartum hemorrhage guidelines was determined. Semi-structured interviews were conducted with maternal healthcare practitioners. Of 154 women, individual AMTSL, in the form of administering a uterotonic during the third stage of labor, controlled cord traction, or delayed cord clamping, occurred in 105 (68.2%), 119 (77.3%), and, of a subset of 60 patients, 37 (61.7%) individuals, respectively. However, only 18 of 53 (34.0%) individuals observed for receipt of all of the three AMTSL components received all of the essential elements of AMTSL. Three major themes influencing the uptake of evidence-based practice were identified through 18 interviews: healthcare system issues; current knowledge, awareness, and use of clinical guidelines; and healthcare practitioner attitudes to updating their clinical practice. Overall guideline adherence was low. There is a need to address context-specific barriers to uptake, ensuring guideline implementation to reduce maternal mortality in low-resource settings.

Adoption and practice of evidence-based obstetric care among Nigerian obstetricians

Adoption and practice of evidence-based obstetric care among Nigerian obstetricians

Mobility and maternal position during childbirth in Tanzania: an exploratory study at four government hospitals.

BackgroundEmerging research evidence suggests a potential benefit in being upright in the first stage of labour and a systematic review of trials suggests both benefits and harmful effects associated with being upright in the second stage of labour. Implementing evidence-based obstetric care in African countries with scarce resources is particularly challenging, and requires an understanding of the cumulative nature of science and commitment to applying the most up to date evidence to clinical decisions. In this study, we documented current practice rates, explored the barriers and opportunities to implementing these procedures from the provider perspective, and documented women's preferences and satisfaction with care.MethodsThis was an exploratory study using quantitative and qualitative methods. Practice rates were determined by exit interviews with a consecutive sample of postnatal women. Provider views were explored using semi-structured interviews (with doctors and traditional birth attendants) and focus group discussions (with midwives). The study was conducted at four government hospitals, two in Dar es Salaam and two in the neighbouring Coast region, Tanzania.Main outcome measuresPractice rates for mobility during labour and delivery position; women's experiences, preferences and views about the care provided; and provider views of current practice and barriers and opportunities to evidence-based obstetric practice.ResultsAcross all study sites more women were mobile at home (15.0%) than in the labour ward (2.9%), but movement was quite restricted at home before women were admitted to labour ward (51.6% chose to rest with little movement). Supine position for delivery was used routinely at all four hospitals; this was consistent with women's preferred choice of position, although very few women are aware of other positions. Qualitative findings suggest obstetricians and midwives favoured confining to bed during the first stage of labour, and supine position for delivery.ConclusionsThe barriers to change appear to be complicated and require providers to want to change, and women to be informed of alternative positions during the first stage of labour and delivery. We believe that highlighting the gap between actual practice and current evidence provides a platform for dialogue with providers to evaluate the threats and opportunities for changing practice.

Evidence-based obstetric care in South Africa--influencing practice through the 'Better Births Initiative'.

Ensuring that health professionals practise according to evidence-based standards is important since it affects the quality and cost of care patients receive. The purpose of this research was to use a focused change programme (the Better Births Initiative) to influence obstetric practice of 10 hospitals in Gauteng, South Africa. The findings show some important improvements in practice following the implementation of the BBI; providers at some sites reduced the use of enemas, shaving and episiotomy, and increased use of oral fluids and companionship during labour. Qualitative data suggest that an interactive approach to implementing evidence-based practice can influence health professionals decisions to change practice, and that good working relationships and enthusiastic staff are central to effective change.

Evidence-based obstetrics in four hospitals in China: An observational study to explore clinical practice, women's preferences and provider's views.

BackgroundEvidence-based obstetric care is widely promoted in developing countries, but the success of implementation is not known. Using selected childbirth care procedures in four hospitals in Shanghai, we compared practice against evidence-based information, and explored user and provider views about each procedure.MethodsObservational study. Using the Cochrane Library, we identified six procedures that should be avoided as routine and two that should be encouraged. Procedure rate determined by exit interviews with women, verified using hospital notes. Views of women and providers explored with in depth interviews.The study sites were three hospitals in Shanghai and one in neighbouring province of Jiangsu. 150 women at each centre for procedure rate, and 48 in-depth interviews with women and providers.ResultsVaginal births were 50% (303/599) of the total. Of the six practices where evidence suggests they should be avoided as routine, three were performed with rates above 70%: pubic shaving (3 hospitals), rectal examination (3 hospitals), and episiotomy (3 hospitals). Most women delivered lying down, pain relief was rarely given, and only in the urban district hospital did women routinely have a companion. Most women wanted support or companionship during labour and to be given pain relief; but current practice is insufficient to meet women's needs.ConclusionObstetric practice is not following best available evidence in the hospitals studied. There is a need to adjust hospital policy to support the use of interventions proven to be of benefit to women during childbirth, and develop approaches that ensure clinical practice changes.