Increase In Delivery Rate Research Articles

Dynamic Programming Implementation for Delivery Route Optimization in E-Commerce Logistics

The rapid growth of e-commerce has created new challenges in logistics optimization, particularly in terms of delivery route efficiency. This research develops a dynamic programming model to optimize delivery routes in the context of e-commerce in Indonesia. Using a modified Vehicle Routing Problem with Time Windows (VRPTW) approach, we implemented an algorithm that considers various factors such as distance, time, and cost. Simulations using synthetic datasets showed efficiency improvements of 18.7% in travel distance and 22.3% in delivery time compared to conventional methods. Field trials with an e-commerce partner resulted in a 21.5% reduction in travel distance and an increase in on-time delivery rate from 87% to 94%. Sensitivity analysis revealed that the algorithm's performance is most affected by demand fluctuations and changes in traffic conditions. Implementation challenges include integration with existing systems and consideration of workforce impact. This research opens avenues for further development in algorithm scalability, integration of sustainability factors, and adaptation to various geographical contexts, demonstrating significant potential for improving e-commerce logistics efficiency in the future.

Advancements in reperfusion rates and quality of care for ST-segment elevation myocardial infarction: a ten-year evaluation of Salvador's STEMI network.

Continuous investment and systematic evaluation of program accomplishments are required to achieve excellence in ST-segment elevation myocardial infarction (STEMI) care, especially in resource-limited settings. Therefore, this study evaluates the impact of problem-driven interventions on reperfusion use rate in a long-term operating STEMI network from a low- to middle-income country. This is a healthcare improvement evaluation study of Salvador's public STEMI network in a quasi-experimental design, comparing data from 2009 to 2010 (pre-intervention) and 2019-2020 (post-intervention). There were evaluated all confirmed STEMI cases assisted in both periods. The interventions, implemented since 2017, included: expanding the support team, defining criteria to be a spoke, and initiating continuous education activities. The primary outcome was the rate of patients undergoing reperfusion, with secondary outcomes being time from door-to-ECG (D2E) and ECG-to-STEMI-team trigger (E2T). Over ten years, the network's coverage increased by 300,000 individuals, and expanded by 1,800 km2. A total of 885 records were analyzed, 287 in the pre-intervention group (182 men [63·4%]; mean [SD] age 62·1 [12·5] years) and 598 in the post-intervention group (356 men [59·5%]; mean [SD] age 61.9 [11·8] years). It was noticed a substantial increase in reperfusion delivery rate (90 [31%] vs. 431 [73%]; P = 001) and reductions in time from D2E (159 [83-340] vs. 29 [15-63], P = 001), and E2T (31 [21-44] vs. 16 [6-40], P = 001). The strategies adopted by Salvador's STEMI network were associated with significant improvements in the rate of patients undergoing reperfusion and in D2E and E2T. However, the mortality rate remains high.

EVALUATION OF MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH BORDERLINE AFI AND OLIGOHYDRAMNIOS IN THIRD TRIMESTER: A TERTIARY CARE HOSPITAL-BASED STUDY

Objectives: Objectives of our study were (1) to study and compare obstetric outcome in women with oligohydramnios, borderline amniotic fluid index (AFI), and normal AFI in terms of (a) type of labor (spontaneous/induced) and (b) mode of delivery-C-section or vaginal delivery and (2) to study and compare perinatal outcome in women with oligohydramnios, borderline AFI, and normal AFI in terms of (a) prematurity, (b) APGAR score at 1 and 5 min, (c) fetal distress, (d) low birth weight, (e) weight for gestational age, (f) neonatal intensive care unit (NICU) admission, (g) cause of NICU admission, and (h) neonatal deaths. Methods: This prospective and comparative study was conducted in Rajindra Hospital Patiala, over a period of 1 year. Women with ≥34 weeks POG were subjected to ultrasonography. They were then divided into following three groups of 50 women each depending upon AFI: Group A – oligohydramnios (AFI <5 cm), Group B – borderline AFI (AFI 5–8 cm), and Group C – normal AFI (AFI >8–25 cm). Patients were followed up to 40 weeks POG or till delivery occurred or decision for C-section was taken. Results: Perinatal outcome was adversely affected by decrease in AFI in terms of increase in rate of preterm delivery, small for gestational age babies, low birth weight babies, and neonatal deaths. Conclusion: Measurement of AFI is an important tool for prediction of adverse neonatal outcome

Difference in the mode of delivery in obstetric patients who have experienced intimate partner or sexual violence compared to those who have not: A systematic review and meta‐analysis

AbstractBackgroundA history of intimate partner violence (IPV) and/or sexual violence may impact a patient's birth experience. Limited information is available on the potential for re‐traumatisation through routine obstetrical practices and the effect on mode of delivery.ObjectivesTo identify whether there is a difference in mode of delivery between obstetrics patients who have experienced IPV/sexual violence compared to those who have not.Search StrategyMEDLINE and EMBASE were searched through inception to February 2024 for terms related to obstetric mode of delivery, IPV and sexual abuse.Selection CriteriaPeer‐reviewed, retrospective and prospective studies that contained original data.Data Collection and AnalysisTwo authors independently conducted data extraction. A random‐effects meta‐analysis was used to pool outcomes. Cochrane's chi‐squared test and the I2 statistic was used to examine the statistical heterogeneity of pooled effect estimates. All studies were evaluated using the risk of bias in a non‐randomised study‐I tool.Main ResultsThirty studies (n = 280 864) were eligible for inclusion. The likelihood of caesarean delivery was significantly higher in those who had experienced IPV/sexual violence compared to those who had not: OR = 1.16, CI = 1.05–1.27; I2 = 71. Pooled analysis of reported operative delivery rates did not reveal any significant increase in operative delivery rate for those who had experienced IPV/sexual violence versus those who had not: OR = 1.14, 95% CI = 0.89–1.45, I2 = 77%. Risk of bias for the included studies were moderate to serious.ConclusionsObstetrics patients with a history of IPV/sexual violence appear to be more likely to deliver via caesarean section as compared to those who do not.

HWMP-based secure communication of multi-agent systems

Multi-agent systems (MAS), known for their autonomy, fault tolerance, and flexible collaboration capabilities, are widely used in various fields. Communication security is one of the most critical problems of MAS tasks. Once a malicious attacker invades agents in the system, it brings massive threats to the entire system. It tampers with routing messages, discards packets, and paralyzes the communication network. To implement collaboration tasks of MASs safely and efficiently, this work makes security improvements on the hybrid wireless mesh protocol (HWMP) with an additional authentication system. We enhance the proactive and reactive mode of the HWMP and apply it to an integrated system, i.e., the MAS formation control as a proper instance. We present a HWMP-based secure communication model (HSCM) for MASs. The theoretical analysis and simulation results demonstrate a significant enhancement in network performance under various threats, including packet loss rate, throughput, etc. The results indicate that HSCM plays a significant role in resisting common attacks (such as black hole and flooding attacks) when compared to multi-agent systems without any security protection. There is an approximate 30% increase in packet delivery rate, a substantial enhancement in throughput, and a reduction in routing overhead. The latency also fluctuates within reasonable bounds. Our solution provides secure communication for formation control under malicious attacks.

Peregrine falcons shift mean and variance in provisioning in response to increasing brood demand.

The hierarchical model of provisioning posits that parents employ a strategic, sequential use of three provisioning tactics as offspring demand increases (e.g., due to increasing brood size and age). Namely, increasing delivery rate (reducing intervals between provisioning visits), expanding provisioned diet breadth, and adopting variance-sensitive provisioning. We evaluated this model in an Arctic breeding population of Peregrine falcons (Falco peregrinus tundrius) by analyzing changes in inter-visit-intervals (IVIs) and residual variance in IVIs across 7 study years. Data were collected using motion-sensitive nest camera images and analyzed using Bayesian mixed effect models. We found strong support for a decrease in IVIs (i.e., increase in delivery rates) between provisioning visits and an increase in residual variance in IVIs with increasing nestling age, consistent with the notion that peregrines shift to variance-prone provisioning strategies with increasing nestling demand. However, support for predictions made based on the hierarchical model of tactics for coping with increased brood demand was equivocal as we did not find evidence in support of expected covariances between random effects (i.e., between IVI to an average sized brood (intercept), change in IVI with brood demand (slope) or variance in IVI). Overall, our study provides important biological insights into how parents cope with increased brood demand.

Fetomaternal Outcome of Referred Obstetric Patients in a Tertiary Centre in North East India: A Cross-sectional Study

Introduction: Referral of patients has improved fetomaternal outcomes in developing countries like India. Identifying high-risk obstetric cases, severe maternal complications, and promptly referring them to a centre equipped with Basic Emergency Obstetric and Newborn Care (BEmONC) helps reduce morbidity and mortality. Aim: To examine the clinical profile of referred obstetric patients admitted to a tertiary care centre and analyse the characteristics of admission, referral pattern, level of delay, and their fetomaternal outcomes. Materials and Methods: A hospital-based observational crosssectional study was conducted from July 1, 2021, to June 30, 2022, at Assam Medical College and Hospital, Dibrugarh in Assam, India. The study included 700 referred obstetric patients from private and public healthcare settings. Variables such as place of referral, referrer (medical officer/self-referral/staff nurse/ specialists), delay in referral, reasons for referral, pregnancy period during referral, diagnosis at admission and referral, availability of proper referral documents, and fetomaternal outcomes such as mode of delivery and gestational age at delivery were assessed. Categorical variables were summarised as proportions and percentages. Results: Out of the total 18,245 obstetric admissions during the study period, approximately 14,500 patients were referred, accounting for 80% of all admissions. Among the 700 study participants, 616 (88%) referrals were from nearby public sectors. A total of 147 (21%) experienced delay due to transportation. 644 (92%) had referral slips, but only 224 (32%) had proper documentation. A number of 322 (46%) were intrapartum referrals. A total of 350 (50%) were primigravida, while 344 (49%) were multigravida. Apart from these 694 pregnant mothers, six referrals were for babieswithout any maternal complications or high risk factors. 112 (16%) referrals were for cases of IUGR and oligohydramnios, and 98 (14%) were preterm referrals. A total number of 276 (47%) deliveries were performed via caesarean section. A total of 35 patients were discharged antepartum, and there were nine maternal deaths. Additionally, 148 neonates required ICU admissions, 225 were preterm, and 558 babies were discharged. Conclusion: Referrals were made for both maternal and foetal causes. The majority of obstetric admissions in our institution were referrals, resulting in an increased delivery rate and a higher trend of caesarean section. The presence of a well-equipped NICU also contributed to the referral pattern.

The Impact of State Mandated Financial Coverage for Donor Egg In Vitro Fertilization (IVF) Cycles on Choosing Fresh Eggs from Infertile Donor vs. Paid Donors vs. Frozen Egg Banks

We sought to determine if using infertile oocyte donors donating only half of the eggs collected to recipients, had comparable live delivery rates following fresh and frozen embryo transfer (ET) when compared to oocytes obtained from compensated donors with a single recipient, compensated donors split between two recipients, or an oocyte bank. A retrospective review of 1,361 in vitro fertilization-embryo transfer (IVF-ET) cycles comparing live delivery rates after fresh ET and live delivery rates per retrieval by donor oocyte source was performed. Live delivery rates per fresh ET showed no significant difference between the four-oocyte sources. However, using an infertile donor had a statistically significant increase in live delivery rate per retrieval when compared to using a compensated donor split between two recipients or an oocyte bank. There was a 15% decrease in live delivery rate per retrieval when using an infertile donor compared to a compensated donor with a single recipient. Financial burden of infertility services has been a long-standing barrier to infertility treatment access. Sharing oocytes with an infertile donor can have financial advantage without significant sacrifice of success rates. It is especially cost saving for recipients in mandated states who actually are financially reimbursed for the majority of the cost of the IVF cycle.

ПРОБЛЕМЫ РАЗВИТИЯ ОТРАСЛИ ТРАНСПОРТНОЙ ЛОГИСТИКИ В УСЛОВИЯХ ПАНДЕМИИ И РОСТА E-COMMERCE

The article traces the chain of factors leading to an increase in delivery rates. A comprehensive description of the transport industry in Russia in the context of a pandemic and accelerated growth of e-commerce, factors influencing the industry, including government actions, is given. Recommendations have been developed to improve the current situation. The prevailing methods of analysis are: construction of analogies, information analysis, synthesis, comparison. An assessment of the impact of coronavirus infection on the situation of the transport industry is given, a comparison with 2019 is made. The current situation of transport in the Russian industry is twofold: traffic volumes are growing, the consequences of the pandemic are being eliminated, at the same time the situation is complicated by the shortage of semiconductors and the tense political situation around Russia. The authors call for more active measures of state support for the industry.

Attributable factors for the rising cesarean delivery rate over 3 decades: an observational cohort study

Cesarean delivery rates continue to rise globally, the reasons for which are incompletely understood. We aimed to characterize the attributable factors for the increasing cesarean delivery rates over a 30-year period within our health network. This was a planned observational cohort study across 2 hospitals (a large tertiary referral hospital and a metropolitan hospital) in Sydney, Australia using data from a previously published study. The following 2 time periods were compared: 1989-99 and 2009-16, between which the cesarean delivery rate increased from 19% to 30%. The participants were all women who had a cesarean delivery after 24 weeks' gestational age. The data were analyzed using multiple imputation and robust Poisson regression to calculate the differences in the adjusted and unadjusted relative risk of cesarean delivery and estimate the changes in the cesarean delivery rate attributable to maternal and clinical factors. The primary outcome was cesarean delivery. After 576 exclusions, 102,589 births were included in the analysis. Fifty-six percent of the increase in the rate of cesarean delivery was attributed to changes in the distribution of the maternal age, body mass index, and parity and to a history of previous cesarean delivery. An additional 10% of the increase was attributed to changes in the obstetrical management of the following high-risk pregnancies: multiple gestation, malpresentation (mainly breech), and preterm singleton birth. When prelabor cesarean deliveries for maternal choice, suspected fetal compromise, previous pregnancy issues, and suspected large fetus were excluded, 78% of the increase was attributed to either maternal factors or changes in the obstetrical management of these high-risk pregnancies. Most of the steep rise in the cesarean delivery rate from 19% to 30% was attributed to changes in the maternal demographic and clinical factors. This observation is relevant to developing preventative strategies that account for nulliparity, age, body mass index, and management of high-risk pregnancies.

The effect of Hyoscine Butylbromide on the rate of vaginal delivery in cases of secondary arrest of cervical dilatation: A rondomized controlled clinical trial

Abstract Background For decades, health providers have worked to manage labor actively and safely, with the goal of shortening the duration of painful labor. Reduction of cesarean sections and maternal complication is also an important aspect of labor management. Antispasmodic are commonly administrating during labor in both developing and developed countries, although there is a paucity of scientific reports validating this. Hyoscine butylbromide is an effective antispasmodic drug. Therefore, We aim to assess efficacy of Hyoscine butylbromide on rate of vaginal delivery in cases of 2ry arrest of cervical dilatation. Objective To assess whether the intravenous injection of hyoscine butylbromide is effective in progress of labor in which cases with 2ry arrest of cervical dilatation. Patients and Methods The study included 100 pregnant women (PG, P1, P2, P3) conducted at Ain Shams University Maternity Hospital, the inclusion Criteria were: term uncomplicated singleton pregnancy in a spontaneous active labor, with cephalic presentation. The patient must be free from any medical disorder associated with pregnancy and free from any obstetric complication. Cases were subdivided into 2 groups: Study group: 50 patients received 40mg iv Hyoscine Butylbromide (as Buscopan 20mg\mrl) when the cervix >4cm dilated and was >50% effaced. Control group: 50 patients received 2ml saline as placebo. Results Significant increase in vaginal delivery rate (72%) in Hyoscine group; compared to Saline group (52%); with significant statistical difference (p = 0.04). Highly significant decrease in 1st and 2nd stage labor time in Hyoscine group; compared to Saline group; with highly significant statistical difference (p < 0.05 respectively). These results observed without significant difference as regards 3rd stage labor time and postpartum hemorrhage (p > 0.05), APGAR score and NICU admission (p > 0.05). Conclusion From the current study we can conclude that HBB 40 mg is safe and effective in increasing vaginal delivary rate in cases of 2ry arrest of 12 dilatation. It is effective in decreasing first and second stage of labor. It has no maternal or neonatal adverse effect. It is easy and available.

A City-Wide Crowdsourcing Delivery System with Reinforcement Learning

The revolution of online shopping in recent years demands corresponding evolution in delivery services in urban areas. To cater to this trend, delivery by the crowd has become an alternative to the traditional delivery services thanks to the advances in ubiquitous computing. Notably, some studies use public transportation for crowdsourcing delivery, given its low-cost delivery network with millions of passengers as potential couriers. However, multiple practical impact factors are not considered in existing public-transport-based crowdsourcing delivery studies due to a lack of data and limited ubiquitous computing infrastructures in the past. In this work, we design a crowdsourcing delivery system based on public transport, considering the practical factors of time constraints, multi-hop delivery, and profits. To incorporate the impact factors, we build a reinforcement learning model to learn the optimal order dispatching strategies from massive passenger data and package data. The order dispatching problem is formulated as a sequential decision making problem for the packages routing, i.e., select the next station for the package. A delivery time estimation module is designed to accelerate the training process and provide statistical delivery time guarantee. Three months of real-world public transportation data and one month of package delivery data from an on-demand delivery platform in Shenzhen are used in the evaluation. Compared with existing crowdsourcing delivery algorithms and widely used baselines, we achieve a 40% increase in profit rates and a 29% increase in delivery rates. Comparison with other reinforcement learning algorithms shows that we can improve the profit rate and the delivery rate by 9% and 8% by using time estimation in action filtering. We share the data used in the project to the community for other researchers to validate our results and conduct further research.1 [1].

Study the depth impact of sucker-rod pumps running on delivery rate

As it is known, currently, the fields at the last stage of development are operated predominantly with sucker-rod pumps. Their operation is usually carried out in quite complicated technological and hydrodynamic conditions dramatically affecting the operation efficiency. Based on the actual field data, the paper studies the possible impact of the depth of sucker-rod pump running on the delivery rate, which is one of the indexes of operation of the whole sucker-rod pump unit. The values of delivery rates by oil and water have been calculated and their functional dependencies on the depth of sucker-rod pumps running developed as well. The results justified the increase of delivery rate by oil and its decrease by water in reviewed value diapasons. Mathematical models of developed dependencies have been obtained as well. As a result of conducted studies, the practicability of the increase of pump setting depth in operation conditions of reviewed field is justified.

OPTIMIZING CLINICAL APPROACH TO THE FORM OF DELIVERY DURING PREGNANCY IN PATIENTS WITH CARDIAC DISEASE; A REVIEW OF THE EFFECTS OF PRACTICE CHANGE BY CONCURRING TO INTERNATIONAL GUIDELINES

Objective: To assess if adherence to international guidelines for pregnant cardiac patients’ mode of delivery is achievable with available local resources.
 Study Design: Prospective quasi experimental descriptive study.
 Place and Duration of Study: All Pregnant patients with cardiac disease reporting to Armed Forces Institute of Cardiac Disease/National Institute of Heart Disease (AFIC/NIHD) who were admitted for and were delivered from Oct 2009 to Sep 2011 were included in the study.
 Methodology: International guidelines and recommendations for mode of delivery for cardiac patients with pregnancy were followed for patients. Caesarean sections were reserved only for obstetrical reasons and absolute cardiac indications. The patients with first trimester miscarriage were not included. Data was collected on a personal computer Microsoft excel sheet. Frequency was calculated from the data entered. The reduction in caesarean section rate and increase in vaginal delivery rate as per guidelines without an increase in maternal mortality, was the main outcome.
 Results: Total of 221 patients were delivered in the 2 year period between October 2009 to September 2011 at AFIC/NIHD. The caesarean section rate the year before 2008-2009 had been 48.6%. After the change in practice by concurring to international guidelines, the caesarean section rate for the 2 year period dropped to 26.7%. The hospital maternal deaths were 5. This was slightly better to the year 2008-2009 which had 3 maternal deaths.
 Conclusion: It’s possible to adhere to international recommendations and protocols for pregnant cardiac patients and achieve internationally comparable outcome in terms of mode of delivery without increasing current institutional maternal mortality rate with local hospital resources.

Changes in the Frequency of Cesarean Delivery in Nulliparous Women in Labor in a Canadian Population, 1992-2018.

To examine the relative contribution of changes in patient demographics and physician management to changes in the cesarean delivery rate in labor among nulliparous women. We conducted a retrospective cohort study of 485,451 births to nulliparous women who experienced labor at or beyond 35 weeks of gestation in Alberta, Canada, from 1992 to 2018. The data were from a province-wide perinatal database. The primary outcome was cesarean delivery. Multivariate logistic regression and calculation of population attributable risk for identified risk factors were performed. The cesarean delivery rate increased from 12.5% in 1992 to 24% in 2018. The prevalence of maternal risk factors for cesarean delivery such as obesity, maternal age 35 years or older at delivery, and comorbidities increased over the study period. However, this did not account for the increase in cesarean delivery, because the frequency of cesarean delivery increased irrespective of risk status. Additionally, the population-attributable risk for each risk factor was stable across the study period. For example, for maternal age 35 years or older at delivery, the number of cesarean deliveries attributable to this factor (the population-attributable risk) was 0.9 per 100 deliveries in 1992-1998 and 1 per 100 in 2014-2018. The proportion of cesarean deliveries in which nonreassuring fetal status was the indication increased from 30.1% in 1992 to 51.1% in 2018. The absolute rate of cesarean delivery in the second stage of labor increased from 3.1% in 1992 to 5.9% in 2018. This was due to a significant increase, among those who entered the second stage, in cesarean delivery without a trial of forceps, from 2.5% in 1992 to 7.0% in 2018. The observed doubling of the rate of cesarean delivery in labor in first-time mothers was not driven by patient risk factors. Increases in the rate of cesarean delivery for nonreassuring fetal status and decreased operative vaginal deliveries were important factors.

Lower segment caesarian section & morbidly adherent placenta

The incidence of placenta accreta has increased dramatically over the last three decades, in concert with increase in caesarean delivery rate.1 Placenta previa and caesarean section are significant risk factors. Morbidly adherent placenta is associated with high fetomaternal morbidity and mortality. Keywords: Caesarian section, Placenta previa, Morbidly adherent placenta, Ultrasound.

Prospective study of timing of elective caesarean section at different gestational ages to assess neonatal outcome in tertiary hospital, New Delhi

Timing of elective caesarean deliveries at term has become an important issue nowadays due to the progressive increase in caesarean delivery rates in recent years all over the world. Advanced maternal age at conception, legal considerations, assisted reproductive techniques and maternal request play an important role in the increased rates of elective repeated caesarean delivery. However the most important cause is the increased number of cases with repeated caesarean sections. Hence, study was undertaken with the aim to find correlation between gestational age of elective caesarean section performed at 38 weeks, 39 weeks, 40 weeks and neonatal outcome. A prospective comparative study consisting of 750 patients was done over a period of one and half year in Department of Obstetrics and Gynaecology Dr. Baba Saheb Ambedkar Hospital in Delhi. Neonatal outcomes were based on: Birth weight, apgar score (at 1 and 5 minutes), Respiratory complications, Hypothermia (axillary temperature

Thermochromic Tissue Phantoms for Evaluating Temperature Distribution in Simulated Clinical Applications of Pulsed Electric Field Therapies.

Background: Irreversible electroporation (IRE) induces cell death through nonthermal mechanisms, however, in extreme cases, the treatments can induce deleterious thermal transients. This study utilizes a thermochromic tissue phantom to enable visualization of regions exposed to temperatures above 60°C. Materials and Methods: Poly(vinyl alcohol) hydrogels supplemented with thermochromic ink were characterized and processed to match the electrical properties of liver tissue. Three thousand volt high-frequency IRE protocols were administered with delivery rates of 100 and 200 μs/s. The effect of supplemental internal applicator cooling was then characterized. Results: Baseline treatments resulted thermal areas of 0.73 cm2, which decreased to 0.05 cm2 with electrode cooling. Increased delivery rates (200 μs/s) resulted in thermal areas of 1.5 and 0.6 cm2 without and with cooling, respectively. Conclusions: Thermochromic tissue phantoms enable rapid characterization of thermal effects associated with pulsed electric field treatments. Active cooling of applicators can significantly reduce the quantity of tissue exposed to deleterious temperatures.

Institutional deliveries and stillbirth and neonatal mortality in the Global Network's Maternal and Newborn Health Registry

BackgroundFew studies have shown how the move toward institutional delivery in low and middle-income countries (LMIC) impacts stillbirth and newborn mortality.ObjectivesThe study evaluated trends in institutional delivery in research sites in Belagavi and Nagpur India, Guatemala, Kenya, Pakistan, and Zambia from 2010 to 2018 and compared them to changes in the rates of neonatal mortality and stillbirth.MethodsWe analyzed data from a nine-year interval captured in the Global Network (GN) Maternal Newborn Health Registry (MNHR). Mortality rates were estimated from generalized estimating equations controlling for within-cluster correlation. Cluster-level analyses were performed to assess the association between institutional delivery and mortality rates.ResultsFrom 2010 to 2018, a total of 413,377 deliveries in 80 clusters across 6 sites in 5 countries were included in these analyses. An increase in the proportion of institutional deliveries occurred in all sites, with a range in 2018 from 57.7 to 99.8%. In 2010, the stillbirth rates ranged from 19.3 per 1000 births in the Kenyan site to 46.2 per 1000 births in the Pakistani site and by 2018, ranged from 9.7 per 1000 births in the Belagavi, India site to 40.8 per 1000 births in the Pakistani site. The 2010 neonatal mortality rates ranged from 19.0 per 1000 live births in the Kenyan site to 51.3 per 1000 live births in the Pakistani site with the 2018 neonatal mortality rates ranging from 9.2 per 1000 live births in the Zambian site to 50.2 per 1000 live births in the Pakistani site. In multivariate modeling, in some but not all sites, the reductions in stillbirth and neonatal death were significantly associated with an increase in the institutional deliveries.ConclusionsThere was an increase in institutional delivery rates in all sites and a reduction in stillbirth and neonatal mortality rates in some of the GN sites over the past decade. The relationship between institutional delivery and a decrease in mortality was significant in some but not all sites. However, the stillbirth and neonatal mortality rates remain at high levels. Understanding the relationship between institutional delivery and stillbirth and neonatal deaths in resource-limited environments will enable development of targeted interventions for reducing the mortality burden.Trial registrationThe study is registered at clinicaltrials.gov. ClinicalTrial.gov Trial Registration: NCT01073475.

Foley Bulb Added to an Oral Misoprostol Induction Protocol: A Cluster Randomized Trial.

To evaluate whether the induction of labor in term gravid women with cervical dilation 2 cm or less and intact membranes by using oral misoprostol preceded by transcervical Foley bulb placement results in a significantly increased vaginal delivery rate compared with the use of oral misoprostol alone. We randomized the induction method by week of admission to labor and delivery, with each week group described as a cluster in a block randomized design. Women with gestational age of 37 weeks or greater, cervical dilation 2 cm or less, intact membranes, and indication for labor induction were included. Study arms were either 100 micrograms of oral misoprostol after transcervical Foley bulb placement or 100 micrograms of oral misoprostol alone. The primary outcome was vaginal delivery with the first induction attempt. Secondary outcomes included time to delivery, clinical chorioamnionitis (maternal temperature of 38°C or greater during labor with or without fundal tenderness, without other identified cause), cesarean delivery indication, and adverse outcomes. We estimated that a sample size of 1,077 per arm was needed to detect a 5% increase in vaginal delivery rate with a type I error of 5% and power of 80%, accounting for interim analysis and cluster size of 30 inductions per week. This was a pragmatic trial, and analysis was by intention-to-treat. From January 1, 2018, to May 13, 2019, 1,117 women (34 clusters) were assigned to oral misoprostol plus Foley and 1,110 women (34 clusters) to oral misoprostol alone. Demographic characteristics were similar. Vaginal delivery at the first induction occurred in 78% of the misoprostol plus Foley arm and in 77% of the misoprostol arm (relative risk [RR] 1.00; 95% CI 0.96-1.05; adjusted relative risk [aRR], 1.00; 95% CI 0.95-1.05). Clinical chorioamnionitis occurred in 18% of the misoprostol plus Foley arm and in 14% of the misoprostol arm (RR 1.30; 95% CI 1.07-1.58; aRR 1.30; 95% CI 1.08-1.56). There were no differences in neonatal outcomes. Induction of labor in gravid women at term with intact membranes by using oral misoprostol plus Foley bulb did not result in a higher vaginal delivery rate, but it did result in more clinical chorioamnionitis compared with the use of oral misoprostol alone. ClinicalTrials.gov, NCT03407625.