Mode Of Delivery Research Articles

A prehabilitation programme is feasible and acceptable for mild-to-moderately frail patients undergoing cardiac surgeries

Abstract Background Preoperative frailty is a strong prognostication in cardiac surgical patients to predict poorer health outcomes. Intervening at the preoperative stage through prehabilitation is gaining increasing research attention. Previous studies tested a single frailty-reversing strategy, either nutritional or exercise, the exercise protocols were mainly aerobic-focused, which deviates from the exercise prescription principles suggested for frailty management, rendering an effective prehabilitation intervention is yet to be developed in cardiac surgical patients. Purpose This study aimed to examine the preliminary effects and explore the feasibility of a multi-component frailty-specific prehabilitation programme for mild-to-moderately frail patients undergoing cardiac surgeries/procedures. We hypothesised that compared with patients who receive usual care, patients awaiting cardiac surgeries who participate in the prehabilitation programme would have improved functional capacity, frailty status, quality of life and psychological outcomes, increased serum albumin and reduced C-reactive protein. Methods This study adopted a mixed-method design comprising a pilot randomised controlled trial and a qualitative study. Adult patients with a Clinical Frailty Scale score between 4 and 6, waiting for coronary artery bypass grafting surgery and/or valve repair/replacement, with at least 5 weeks of procedural waiting time and without contraindications for exercise were recruited. They were randomized in a 1:1 ratio to receive the prehabilitation programme or usual care. The programme comprised a structured preoperative education, nutritional optimization, stress management; and a multi-component exercise training with 3 sessions/week and 60 minutes/session. The exercise training lasted at least 4 weeks and maintained throughout the preoperative period. Results Twenty participants were randomized into the intervention (n = 11) or control (n = 9) group. The programme was feasible, acceptable and no severe adverse events were recorded. The lost to follow-up rate was 7.9%, and the overall attendance was 96%. The intervention group showed significantly greater improvement in functional capacity, frailty status and psychological outcomes than the control group at post-intervention. Participants gave positive comments about the programme and its delivery mode. They expressed that the one-on-one home-based practice enabled them greater confidence to overcome kinesiophobia. Two participants voiced out the preference for exclusive home-based training, rather than having hospital-based training in the first two weeks. Conclusion(s) The prehabilitation programme is feasible and acceptable for patients waiting for cardiac surgeries. It improves the functional performance, frailty status and psychological outcomes in these patients. A full-scale randomised controlled trial is warranted to investigate its longer-term and clinical effects.

A long journey from telemedicine to digital (public) health: the vision of different stakeholders

Abstract The healthcare system willingly adopts new innovative means of communication and solutions offered by computer science. Telemedicine was one of the first terms used in this context. It was initially associated with providing medical services but quickly extended to other areas of health-related activities, including public health. The growth of the global web yielded new prospects for the provision of health services, also resulting in new terms to name the use of information and telecommunication technologies in healthcare. E-health, stemming from the end of 90ies in the 20th century, was initially defined as a new domain strongly associated with public health, especially in the context of access to health information. Quickly, its understanding was extended to all health-related interventions based on innovative digital technologies. Today, digital health and digital public health have emerged as the key terms, signifying the next phase of emerging applications that leverage the advancements made on the technical front. The medical community is probably more inclined to use the former term, while public health professionals are dedicated to the latter. But do these terms carry distinct meanings? Or is it merely a matter of the professional group’s background? Is the focus on individual or population health a differentiating factor? In the meantime, business and technical communities have developed the concept of Health 4.0. This concept emphasizes using technologies like the Internet of Things, cloud computing, big data, and artificial intelligence. However, digital (public) health benefits hugely from these solutions. One can ask whether every professional community needs other concepts and new terms for naming fields, resulting from the multidisciplinary effort. And where are the plain people in this landscape? Do they have sufficient digital and health literacies to accept new modes of health service delivery?

Improving the last mile delivery of vaccines through an informed push model: Experiences, opportunities and costs based on an implementation study in a rural district in Uganda.

Developing countries face challenges in ensuring equitable, timely, and efficient vaccine availability at health facilities. In Uganda, the distribution of vaccines from district stores to the last-mile health facilities is hindered by an unpredictable and unreliable mixed push-pull delivery system. This system often results in poor vaccine management, stock-outs, and missed vaccination opportunities. This pilot study aimed to enhance the efficiency of last-mile vaccine delivery by implementing an informed push model. The specific goals were to improve vaccine lead time, standardize cold chain management during transportation, and evaluate the costs of implementing the informed push model. A mixed methods approach was used to evaluate the impact of the informed push model in Gomba district, Uganda. Both quantitative and qualitative data were collected at baseline and endline. Quantitative data included mode, frequency, lead-time, and costs of vaccine delivery, vaccine stock status, and cold chain maintenance during transportation, gathered through semi-structured interviews. Qualitative data on experiences and challenges were collected using a guide. Descriptive statistics were used for quantitative data analysis, while an ingredients approach was used for costing data. Thematic analysis was applied to qualitative data. The informed push system significantly improved vaccine delivery efficiency and quality in Gomba district. The average lead-time for vaccine delivery reduced from 14 days at baseline to 5 days at endline. Timely vaccine receipt at health facilities increased from 36.8% to 100%. Temperature monitoring during transit improved from 26.3% to 100%. The proportion of facilities experiencing stock-outs dropped from 79.0% to 36.8%. Monthly distribution costs decreased from $494.8 ($0.07 per child) to $445.9 ($0.06 per child). The informed push model is a cost-effective strategy for improving last-mile vaccine delivery by reducing lead times, enhancing cold chain management, and decreasing stock-outs. Integration into the national immunization program is recommended for broader adoption in Uganda.

Innovations in staffing and service delivery structures and modalities in small institutions

AbstractSmall institutions are in a unique and perhaps necessary position to innovate as the field changes, resources falter, and the needs of the next generation of students and families become apparent and quite different from those supported by our historical structures and service modalities. This article examines the literature surrounding historical and innovative practices that higher education can explore to inform the future of student development practice. Additionally, the article explores new structural models and examines the efficacy of retaining the scaled down versions of the structures of large universities instead of creating new modalities that increase staff performance, provide better work/life harmony, create more efficient and effective services and functions, while increasing student engagement and connection.

1.O. Scientific session: Trans & Gender-Diverse Individuals’ Mental & Behavioral Health Risks & Intervention Needs

Abstract Transgender and gender-diverse (TGD) individuals are at a greater risk for various poor mental and behavioral health outcomes than cisgender individuals, including higher rates of suicide, psychiatric diagnoses, and behavioral health problems. For example, research has documented a seven-fold increased risk for lifetime suicide attempts among young TGD people, compared with the general population. Less is known about the age of onset of such mental and behavioral health disparities and how these disparities may vary across other intersectional socio-demographic variables. It has been well-documented that trans and gender-diverse individuals often encounter discrimination and transphobia across various social, educational, professional, administrative, and healthcare settings. This discrimination, as highlighted in the literature, frequently poses obstacles to accessing both general and trans-specific healthcare services due to experiences of discrimination (e.g., misgendering, refusal of care, lack of adequate services). The right and ability to self-determine and the accessibility to gender-affirming care without discrimination are key to closing the gap in TGD individuals’ mental and behavioral health outcomes, and for them to live authentically and thrive. Tailored and affirming mental and behavioral health interventions to reduce these health inequities are pivotal for TGD individuals to achieve the highest attainable standard of physical and mental health: a key fundamental human right. Considerable gaps in the literature remain concerning the onset and determinants of gender identity-based health disparities and healthcare approaches that are respectful, inclusive, non-pathologizing, and grounded in human rights principles for TGD individuals. This workshop intends to address these knowledge gaps by delving into the mental and behavioral health needs of TGD individuals. The workshop seeks to further foster dialogue on strategies to overcome resistance to implementing approaches that uphold the human rights and well-being of these communities. Dr. Richard Bränström (Karolinska Institutet) will present a study that explores the age at which gender identity-based disparities in psychiatric diagnoses and treatment can be first identified. Dr. Gonzales (Vanderbilt University) will examine disparities in mental health and social determinants of health among TGD individuals with private insurance. Dr. Moleiro (Lisbon University Institute) will review TGD persons’ ways of identifying with the choices and trajectories in social, legal, and affirmative healthcare processes in Portugal. Dr. Lelutiu-Weinberger (Columbia University School of Nursing) will present findings from a study that assessed tobacco use and cessation attitudes, facilitators, and barriers to quitting, and intervention components and delivery modality acceptability among TGD individuals, as well as sexual minority individuals, in Romania to inform a tailored and affirming smoking cessation intervention. Key messages • Transgender and gender-diverse are at increased risk for a variety of poor mental and behavioral health compared with the general public. • There is a critical need to foster healthcare services for transgender and gender-diverse individuals that are tailored and affirming.

Delivery mode and subsequent birth rate: A nationwide register-based analysis in Finland.

The study aimed to calculate the subsequent birth rate for different delivery modes, comparing them with spontaneous vaginal deliveries, using a comprehensive nationwide high-quality registry. Data from the National Medical Birth Register (MBR) were used to evaluate the birth rate after different delivery modes. All first deliveries for a mother during the years 2004 to 2016 were included. For these women, all second pregnancies from the MBR during the years 2004 to 2018 were retrieved and combined with the data of the first deliveries. A Cox regression model was used to evaluate the risk for the second pregnancy after giving birth the first time. The results were interpreted with adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). A total of 375 619 women with a first and second pregnancy leading to birth were included in this study. Of these, a total of 50 579 women underwent assisted vaginal delivery, 50 429 had an unplanned cesarean section (CS), 22 021 had elective CS, and 252 593 had spontaneous vaginal delivery as a mode of delivery in their first pregnancy. Women with assisted vaginal delivery (aHR, 1.23 [CI, 1.21-1.24]) and unplanned CS (aHR, 1.03 [CI, 1.02-1.05]) had higher birth rates after the first birth, and women with elective CS as a mode of delivery had lower birth rates (aHR, 0.86 [CI, 0.84-0.88]) when compared with women who had spontaneous vaginal delivery. The findings of this study indicate that the CS operation itself is not the only cause of the observed lower birth rate; rather, there are underlying factors that have a greater impact on birth rates.

Pattern of Birth Defects, Association And Their Outcomes Among Neonates In A Tertiary Care Hospital In Bangladesh

Introduction: Birth defects are one of the major cause of stillbirths and neonatal mortality in developed and developing countries. The prevalence of birth defects varies in different parts of the world. In many cases, the causes are unknown; however, several factors known to be associated are genetic factors, maternal age, health, dietary factors, maternal infections, geographical factors, drugs, smoking and irradiation. Objectives: To identify the pattern of birth defects, association and their outcomes among neonates Methodology: This observational cross-sectional study was conducted in the department of neonatology, Dhaka Medical College Hospital, Dhaka from 1st July 2019 to 30th June 2021. Sample was collected by purposive sampling technique. Total 407 babies were enrolled. Out of them 207 babies were with birth defects in group-A and 200 babies had no birth defects in group-B. Detail demographic data were collected from the informant and recorded in structured case report form. Clinical examination and relevant investigations were done. Data processing work consist of registration schedules, editing computerization, preparation of dummy table, analyzing and matching of data. Results: In this study the two study groups were almost similar with respect to their demographic characteristics like sex, residence, place of delivery, mode of delivery, gestational age, parity and maternal age. The total number of admission during this period was 3050 and total number of birth defects was 207 (6.78%0). In this study on evaluation of maternal risk factors, group-A maternal high blood pressure were in 25.12% cases( OR=1.62;p=.002), maternal diabetes were in 15.46% cases( OR=1.12;p=.001), poor maternal nutritional status was 14.50%( p=.001), history of taking folic acid was 9.66%(OR=0.10;p=.001), 5.80% of the patient had history of exposure to antenatal radiation(OR=.06;p=.001), 4.43% had history of consanguinity(OR=.05;p=.001), 2.420% of women noticed that exposure to pesticides(OR=.025;p=.001), H/O of taking anticonvulsant was 2.420%(OR=.025;p=.001). Group-B was maternal high blood pressure in 7.25% cases(OR=.078;p=.001), maternal diabetes were in 6.28% cases(OR=.067;p=.001), poor maternal nutritional status was 5.80%(p=.001), history of taking folic acid was 4.83% (OR=.051;p=.001), 1.45% of the patient had history of exposure to antenatal radiation(OR=.015;p=.001) and 0.97% had history of consanguinity(OR=.01;p=.001). In this study pattern of birth defects summarized as the cardiovascular system defects was the most commonly affected(26.57%), followed by defects in the head, neck ear,- and eye(19.32%), Syndromes(14.50%), gastrointestinal defects(12.56%), musculoskeletal system defects(10.14%), central nervous system defects (8.70%) and genitourinary system(4.83%) of total defects. In group-A 78.26% of the patients recovered and 23 patients expired during hospital stay (p=.001). In group-B 85.99% of the patients recovered and 17 patients expired. Conclusion: Congenital cardiac defects were the most prevalent anomaly detected. Maternal high blood pressure and diabetes are the risk factors of birth defects in neonates. Antenatal diagnosis and proper management can improve the outcome of these neonates. J Dhaka Med Coll. 2023; 32(1) : 43-50

Pelvic floor-related sexual functioning in the first 24 months postpartum: Findings of a large cross-sectional study.

The pelvic floor is exposed to differing stresses and trauma depending on the mode of birth. At the same time, the pelvic floor plays a crucial role in female sexual functioning (FSF). Whereby FSF encompasses different dimensions, from subjective satisfaction to physiological aspects, such as lack of pain and orgasm ability. The aim of the study presented here is to assess FSF in relationship to postpartum pelvic floor disorder based on the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR), in a large convenience sample and to identify whether there is an association between mode of birth as well as perineal injuries and FSF of women up to 24 months postpartum. We conducted a cross-sectional online survey and recruited via social media women up to 24 months after birth of their last child. FSF was surveyed using the PISQ-IR. Details were also collected on all previous births and birth-related perineal trauma, as well as current breastfeeding, obesity, and socio-demographics. Multivariate models were then calculated to determine a possible association between FSF and birth mode. The data basis is the responses of 2106 survey participants within the first 24 months postpartum. Even 12-24 months postpartum, 21% of respondents are not sexually active, which burdens almost 44% of these women. With regard to mode of delivery, differences in FSF are only evident in individual dimensions of the PISQ-IR. The dimensions "Condition Impact" and "Condition Specific" were significantly associated with more impairments in sexually active respondents up to 12 months postpartum whose last mode of delivery was forceps or vacuum extraction. If a perineal tear had occurred during last birth, this was significantly associated with a lower PISQ-IR subscore in the "Condition Impact," "Condition-Specific," "Global Quality," "Partner-Related," and "Arousal" models. The low variance explanation shows that further relevant factors on female sexuality may exist. The issue of impairments in FSF following childbirth, persisting for an extended period of time, is a significant postpartum concern. Due to the very different dimensions of FSF, the influence of the mode of delivery must be considered in a differentiated way.

Should face-to-face in-person therapy be preserved for some clients with anxiety? Evaluation of Anxiety UK's psychological therapy services before and during the COVID-19 pandemic.

The COVID-19 pandemic initiated a mass switch to psychological therapy being delivered remotely, including at Anxiety UK, a national mental health charity. Understanding the impact of this forced switch could raise implications for the provision of psychological therapies going forwards. To understand whether the forced switch to remote therapy had any impact on outcomes, and if certain groups should continue to be routinely offered certain delivery modalities in future. Data were available for 2323 individuals who accessed Anxiety UK services between January 2019 and October 2021. Demographic data, baseline and discharge anxiety and depression symptoms, and mode of therapy delivery were available.Regression models were built to model (a) the mode of therapy delivery received pre-pandemic using logistic regression, and (b) outcomes pre- and post-pandemic onset within demographic groups. No statistically significant changes in baseline anxiety symptoms, demographics or outcomes were observed before and after the onset of the COVID-19 pandemic.Pre-pandemic, males were more likely to receive online video therapy than telephone therapy (Relative Risk Ratio (RRR) 1.42, [1.01, 1.99]), while older clients were less likely to receive online video therapy (RRR 0.98, [0.97, 0.99]). However, no differences in outcomes were observed post-pandemic onset within these groups, with only the number of sessions of therapy being a significant predictor of outcomes. Anxiety UK services remained effective throughout the pandemic. We observed no evidence that any demographic group had worse outcomes following the forced switch to remote therapy.

Influence of Early Life Factors on the Breast Milk and Fecal Microbiota of Mother–Newborn Dyads

Maternal gut and breast milk (BM) are key in vertically transmission bacteria to infants, shaping their gut microbiota in early life. Although the establishment of early gut microbiota is known, the role of the combined influence of maternal factors and newborn characteristics is not explored. In this study, we aimed to assess the influence of maternal BMI and total body fat, age, delivery mode, and newborn sex on the diversity and composition of the BM and gut microbiota (GM) in mother–newborn dyads. In this cross-sectional study, of the 986 pregnant women candidates, 53 participated, and, finally, 40 mother–newborn dyads exclusively breastfeeding at 20–28 days postpartum were included. Metataxonomic profiling of DNA extracted from BM and fecal samples was conducted using 16S rRNA sequencing. Globally, the findings offer valuable insights that excessive adiposity, age, and C-section delivery influence a lower abundance of specific taxa in the BM, maternal gut, and gut of newborns. Also, the simultaneous analysis of maternal factors and newborn characteristics shows that maternal age and newborn sex explain an important variation in the microbiota composition. These results add to the understanding of the intricate interplay between maternal factors and the microbial communities that influence early-life gut and BM microbiota.

Impact of Attempted Mode of Delivery on Neonatal Outcomes in Nulliparous Individuals According to Body Mass Index.

Objective To compare neonatal and maternal outcomes based on the attempted mode of delivery, stratified by prepregnancy body mass index (BMI kg/m2) in nulliparous individuals. Study Design This was a repeated cross-sectional analysis of US vital statistics Live Birth and Infant Death linked data from 2011 to 2020. The analysis was restricted to nulliparas with singleton pregnancies and cephalic presentation who delivered at term. Our primary outcome was a composite neonatal outcome. We also examined a composite maternal outcome. We compared outcomes between individuals who attempted labor and those who opted for non-labor cesarean delivery, categorized by BMI (< 18.5, 18.5-24.9, 25-29.9, 30-39.9, ≥ 40). To account for significant differences in baseline characteristics between groups, Coarsened Exact Matching was applied using a k-to-k solution. We employed modified Poisson regression and calculated a difference-in-difference (DID) to compare differences in predicted proportions across BMI categories. Results Out of 9,709,958 individuals, 1,083,332 were included in the matched analysis. Compared to attempted vaginal delivery, non-labor cesarean delivery was associated with an increased risk of the composite neonatal outcome across all BMI categories. However, the increase in risk was less pronounced in higher BMI categories compared to the reference group (BMI 18.5-24.9). For maternal outcomes, non-labor cesarean delivery was associated with an increased risk of the composite maternal outcome in the BMI 18.5-24.9 and 25-29.9 categories. In contrast, the risk of adverse maternal outcomes associated with non-labor cesarean delivery was lower in higher BMI groups compared to the reference group, with DID values ranging from -0.12 in the BMI 30-39.9 group to -0.16 in the BMI ≥ 40 group. Conclusion Non-labor cesarean delivery, as compared to attempted vaginal delivery, was associated with adverse neonatal outcomes across all BMI categories, though the relative increase in risk was diminished in higher BMI groups.

Optimization and Application Analysis of the UAV "Last Mile" Mobile Terminal Distribution Station in Rural Area under the Background of E-Commerce

With the booming demands of global consumers, the grand total of international e-commercial procurement in 2024 will be expected to exceed 6.3 trillion USD. Under the pressure of huge orders and shipping lag, figuring out a cost-effective last mile delivery achieving real door-to-door service, especially in rural areas, has become one of the focuses in the international e-commercial market. To better solve this problem, this paper starts with the analysis of international e-commercial status and the feasibility of UAV mobile terminal station launch, taking good account of drone delivery route setting, time schedule, and costs spent to optimize the mobile station moving. Based on a series of experiments to iterate the Unmanned Aerial Vehicle (UAV) mobile terminal station delivery mode, it will provide some insights to the market about how the last mile delivery will develop in the next decade. This paper will focus on applying the hybrid ant colony algorithm to improve truck-drone collaborative last mile delivery route settings and figure out the best delivery route combo for cost saving.

Associations between term cesarean delivery in the first pregnancy and second-pregnancy preterm delivery.

Cesarean delivery has been shown to increase the risk of preterm delivery in future pregnancies. The association could be a direct result of the procedure, or because the indications that led to the cesarean delivery also increase the risk of preterm delivery in later pregnancies. 298 901 mothers with first and second singleton deliveries from 1999 to 2020 were investigated using data from the Medical Birth Registry of Norway linked with Statistics Norway. The mothers were categorized by mode of cesarean delivery (total, emergency and planned) and vaginal delivery at term in the first pregnancy. We used log-binomial regression models to estimate relative risks with 95% confidence intervals (CI) of iatrogenic and spontaneous preterm delivery <37 gestational weeks in the second pregnancy. Second, we explored the role of recurrent placental disease in preterm delivery by comparing estimates in mothers with placental disease in neither or both pregnancies. 8243 mothers (2.8%) had a preterm delivery in the second pregnancy. The adjusted relative risk (aRR) of preterm delivery was 1.24 (95% CI 1.17-1.32) after cesarean compared with vaginal delivery in the first pregnancy. The association was stronger in previous planned compared with emergency cesarean delivery (aRR 1.52, 95% CI 1.30-1.77 and aRR 1.21, 95% CI 1.14-1.29, respectively). Spontaneous preterm delivery was not associated with the previous mode of delivery; the risk was confined to iatrogenic preterm delivery after both emergency and planned cesarean delivery (aRR 1.69, 95% CI 1.52-1.87 and aRR 2.65, 95% CI 2.12-3.30, respectively). Mothers with placental disease in both pregnancies had a sixfold increased risk of preterm delivery in the second pregnancy compared with mothers with no placental disease, however, the association between mode of delivery and subsequent preterm delivery was similar in mothers with and without placental disease in the pregnancies. Compared with vaginal term delivery in the first pregnancy, cesarean delivery increases the risk of iatrogenic, but not spontaneous preterm delivery in the next pregnancy. Although strongly associated with preterm delivery, placental disease had limited influence on the estimates.

Cervical ripening with a double balloon device for 6 h in patients with a long cervix: Secondary analysis of a randomized controlled trial.

To examine whether cervical ripening with a double balloon device for 6 h is as effective as 12 h in patients with a cervical length ≥ 30 mm measured on transvaginal ultrasound before induction of labor, and to determine whether patients with a long cervix need to have the balloon placed for a longer time. This is a secondary analysis of data from a randomized controlled trial that compared maternal and neonatal outcomes between women undergoing cervical ripening with a double balloon device for 6 h (study group) versus 12 h (control group). In this secondary analysis, we included only patients who had cervical length ≥ 30 mm measured on transvaginal ultrasound on admission. Our primary outcome was a Bishop score change after removal of the device. Secondary outcomes included insertion to delivery interval, mode of delivery, and oxytocin infusion duration. Sixty-seven women met the inclusion criteria and were included in the analysis: 33 in the 6-h group and 34 in the 12-h group. Maternal characteristics were similar between both groups. Bishop score difference between the preinsertion and the postremoval scores were similar in the two groups (2.67 ± 1.8 vs. 2.53 ± 1.69, P = 0.76), while insertion to delivery time was 10 h shorter in the 6-h group (20.95 vs. 31.21, P = 0.02; mean difference, -10.26 [95% CI, -19.0 to -1.51]). The other secondary outcomes remained similar in both groups. In women undergoing induction of labor who have a cervical length ≥ 30 mm measured on admission transvaginal ultrasound, removing a double balloon device after 6 h achieved similar Bishop score changes as removal after 12 h, but significantly reduced the time to delivery. REGISTRATION AT CLINICAL TRIALS: https://classic. gov/ct2/show/NCT03045939.

Nomogram Predictive Model for Vaginal Birth after One Prior Cesarean Section: A Retrospective Study

Background: Repeat cesareans pose significant maternal risks, whereas vaginal birth after cesarean (VBAC) offers better outcomes, with a complication rate of 2.4% compared with 3.6% for elective repeat cesareans and 14.1% for failed trial of labor after cesarean (TOLAC). TOLAC rates are low in China, and success rates vary between 60% and 80%. This study aims to develop a nomogram-based predictive model for VBAC in China and improve existing, less rigorous scoring models. Methods: This retrospective cohort study was conducted at Hangzhou Women's Hospital from February 2015 to March 2020, and included 159 parturient attempts at labor after one prior low transverse cesarean section. The participants were divided into two groups based on their mode of delivery for comparison: the VBAC and the TOLAC failure group. Univariate and multivariate logistic regression analyses were conducted to identify independent predictors for VBAC and develop a nomogram predictive model to estimate the success rate of TOLAC. The bootstrap method was used for internal validation of the models. Three different VBAC prediction models were evaluated by plotting receiver operating characteristic (ROC) curves, calibration curves, and decision curves. Results: A total of 127 women had VBAC and 32 women failed TOLAC, with a success rate of 79.9%. Three independent factors affecting the VBAC were identified: gestational age at delivery, Bishop score and newborn birth weight. A predictive nomogram model for the VBAC was constructed that incorporates these three factors. The model showed a good fit (χ2 = 11.94, p = 0.154) with an overall prediction accuracy of 81.1%. The area under the ROC curve was 0.83 (95% CI (confidence interval), 0.76–0.90) (p &lt; 0.001) and the optimal cut-off value was 83.4%. The bootstrap internal validation showed that our predictive model maintained high overall accuracy and specificity, but exhibited low sensitivity and a low Kappa coefficient. Compared to the Grobman model and Jiaming Rao et al. model, our developed prediction model possesses the strongest discriminatory ability and the highest net benefit, followed by the model by Jiaming Rao et al. All three models demonstrate a high degree of fit. Conclusions: Shorter gestational age at delivery, lower newborn birth weight and higher cervical Bishop score are favorable factors for VBAC. The predictive nomogram model for the VBAC after a single cesarean section, constructed with these three factors, has good predictive efficacy. The model is simple to calculate and has practical value in the clinical selection of suitable candidates for TOLAC after a single cesarean section.

Assessing the role of non-state actors in health service delivery and health system resilience in Myanmar

BackgroundDue to the weaknesses of the public health system and its low reach, especially in border areas, provision of health services by non-state actors (NSAs) has historically played an important role in Myanmar. NSAs include local and international NGOs and civil society organisations (CSOs), but also Ethnic Health Organisations (EHOs) in the border areas, as well as the private (for profit) sector. This study aims to understand the changing role of NSAs in the shifting political environment of Myanmar between 2010 and 2022, and to explore their contribution to health system resilience.MethodsOur study includes three main components: a documentary review (n = 22), key informant interviews (KIIs) at central level (n = 14) and two township-level case studies (13 KIIs, 4 FGDs). Mostly qualitative data were collected in 2022 and synthesized, using a health system resilience framework to structure the analysis.ResultsDuring the transition period (2010–2014) and the new political era (2015–2020), while the country gradually transitioned to a democratic system, the government increasingly recognized NSAs. Initially, engagement with NSAs remained focused on disease-specific activities and government oversight was limited, but later it expanded to health system strengthening, including the start of a “convergence” with ethnic health systems. Progress was relatively slow, but defined by a clear vision and plans. The military coup of February 2021 brought a halt to this progress. Collaboration between government and NSAs was interrupted, and NSAs restored previous practices and parallel systems. Initially, most health service provision stopped, but with time coping strategies emerged, which showed the capacity of NSAs to absorb the shocks (focusing on basic services; using informal communication channels; maintaining buffer stocks of supplies) and adapt (changing modes of delivery and supply chains, and adjusting HRH training).ConclusionsThe study highlights the role of NSAs during crises, and provides insights on how the resilience capacities built over time by NSAs to provide services in adverse circumstances have informed the response to the latest crisis. While strategies of absorption and adaptation are noted in the study, we did not identify any transformation strategy – which might indicate the difficulty of NSAs to introduce radical changes when subjected to multiple shocks and a hostile political environment.

Evaluation of Some Antioxidant Parameters (Vitamin E &amp; C), MDA and Hemoglobin Levels, in Women of Reproductive Age, Based on Mode of Child Delivery, in Owerri, Imo State, Nigeria

Childbirth indicates the positive outcome of pregnancy in humans, in which mode of child delivery, which is either by vaginal delivery (VD) or cesarean-section delivery (CS) is considered critical in maintaining maternal health. Antioxidants delay or inhibit cellular damage, mainly through their free radical-scavenging property. Changes in vitamin E and vitamin C antioxidants, lipid peroxidation (MDA) and hemoglobin (Hb) can lead to complications, forming reactive oxygen species (ROS) and cellular imbalance, bringing about oxidative stress (OS). These parameters remove the ROS efficiently and protect the body from the adverse effects of oxidative stress. The purpose of our study was to evaluate the effect of mode of child delivery on maternal VE, VC, MDA and Hb status, in women of reproductive age in Owerri, Imo state, Nigeria. It involved 200 pregnant women, within the reproductive ages of 20 to 39 years, with 100 subjects being those who gave birth through VD and 100 being those who gave birth through CS. Data were analyzed using SPSS version 23, with results expressed as mean ± standard deviation and presented in tables. Independent t-tests and ANOVA were used for comparisons, with p≤0.05 considered significant. The results from this study showed that, women who gave birth through VD had significantly lower VE (p&lt;0.001) and VC (p&lt;0.001) levels compared to those who had CS. Similarly, the levels of MDA were significantly (p&lt;0.001) reduced in women who gave birth through VD compared to those who had CS. The antepartum Hb of VD women was significantly higher than postpartum levels, while the antepartum Hb of CS women was significantly lower compared to the postpartum levels. The results indicate that women who gave birth through VD had significantly reduced VE, VC, MDA and Hb levels, after childbirth, compared to births of CS delivery. It is recommended that antioxidant parameters (Vitamin E &amp; C), MDA and hemoglobin (Hb) levels, be assessed in women during childbirth in order to help in the management of their postpartum conditions.

Pathological fetal heart rate tracing patterns and neonatal outcomes among parturients beyond 32weeks of gestation: a prospective observational study.

Distinct clinical phenotypes of pathological fetal heart rate (FHR) tracings may affect neonatal outcomes differently. This study aimed to determine and differentiate neonatal outcomes amongst the clinical phenotypes of pathological FHR tracing. This prospective observational study included women in labour with pathological fetal heart rate tracing during delivery. Pathological fetal heart rate tracings were characterized into 11 clinical phenotypes and corresponding neonatal and maternal outcomes were recorded. Neonates and mothers were followed till discharge from the hospital. The primary outcome was a 5-min Apgar score. The secondary outcomes were NICU admission, mode of delivery, mode of anesthesia, neonatal morbidity and mortality. 271 women with pathological fetal heart rate tracing at the time of delivery were included in the study. Most of the women (64%) underwent cesarean delivery. The most common pathological fetal heart rate tracing was repetitive late decelerations (24.7%), followed by reduced variability with repetitive variable decelerations (24.4%). The 5-min Apgar score was comparable across all clinical phenotypes of pathological fetal heart rate tracing. Tachycardia with reduced variability was associated with a significantly higher likelihood of NICU admission (aOR 5.03, 95% CI 1.32-19.27, p = 0.018). Reduced variability, repetitive late decelerations and the combination of repetitive late decelerations with prolonged decelerations and reduced variability showed moderately increased odds of NICU admission. The 5-min Apgar score remained comparable in all clinical phenotypes of pathological fetal heart rate tracing. Nonetheless, the odds of NICU admission were significantly higher in women with tachycardia and reduced variability.

Mode of delivery in chorioamnionitis: impact on neonatal and maternal outcomes

BackgroundThe impact of mode of delivery in chorioamnionitis on neonatal outcomes is unclear. This retrospective cohort study compares the rate of early onset neonatal sepsis between vaginal delivery and cesarean section.MethodsSingleton pregnancies at greater than 24 + 0 weeks gestation with live birth and clinically-diagnosed chorioamnionitis from January 1, 2019 to December 31, 2021 were included. Cases with multiple gestations, terminations or histological chorioamnionitis alone were excluded. Rates of early onset neonatal sepsis, select secondary neonatal outcomes and a composite outcome of maternal infectious morbidity were compared using propensity score weighting. Subgroup analysis was done by indication for cesarean section.ResultsAfter chart review, 378 cases were included with 197 delivering vaginally and 181 delivering via cesarean section. The groups differed on age, parity, hypertension, renal disease, gestational age, corticosteroid use, magnesium sulfate use, presence of meconium and percentage meeting Gibbs criteria before propensity score weighting. Rate of early onset neonatal sepsis was greater in the cesarean section group (13.8% versus 3.1%, adjusted risk difference 8.3% [3.5–13.1], p < 0.001). Secondary neonatal outcomes were similar between groups. When compared by indication, the rate of early onset neonatal sepsis was greater in the cesarean section for abnormal fetal surveillance group compared to vaginal delivery but not in the cesarean section for other reasons group. Adjusted rates of secondary neonatal outcomes did not differ between groups. The rate of maternal infectious morbidity was greater with cesarean section. (13.8% versus 1.5% [adjusted risk difference 13.0% [7.1–18.9], p < 0.0001). No other difference in maternal secondary outcomes was identified.ConclusionsThe rate of early onset neonatal sepsis was highest in the cesarean section group, particularly in those with abnormal fetal surveillance. Fetuses affected by or vulnerable to sepsis likely have a greater need for cesarean section.

Reduce, reinforce, and replenish: safeguarding the early-life microbiota to reduce intergenerational health disparities.

Socioeconomic (SE) disparity and health inequity are closely intertwined and associated with cross-generational increases in the rates of multiple chronic non-communicable diseases (NCDs) in North America and beyond. Coinciding with this social trend is an observed loss of biodiversity within the community of colonizing microbes that live in and on our bodies. Researchers have rightfully pointed to the microbiota as a key modifiable factor with the potential to ease existing health inequities. Although a number of studies have connected the adult microbiome to socioeconomic determinants and health outcomes, few studies have investigated the role of the infant microbiome in perpetuating these outcomes across generations. It is an essential and important question as the infant microbiota is highly sensitive to external forces, and observed shifts during this critical window often portend long-term outcomes of health and disease. While this is often studied in the context of direct modulators, such as delivery mode, family size, antibiotic exposure, and breastfeeding, many of these factors are tied to underlying socioeconomic and/or cross-generational factors. Exploring cross-generational socioeconomic and health inequities through the lens of the infant microbiome may provide valuable avenues to break these intergenerational cycles. In this review, we will focus on the impact of social inequality in infant microbiome development and discuss the benefits of prioritizing and restoring early-life microbiota maturation for reducing intergenerational health disparities.