Obstetric Facilities Research Articles

Accountability for quality of care: Monitoring all aspects of quality across a framework adapted for action.

Quality of care is essential to maternal and newborn survival. The multidimensional nature of quality of care means that frameworks are useful for capturing it. The present paper proposes an adaptation to a widely used quality of care framework for maternity services. The framework subdivides quality into two inter-related dimensions-provision and experience of care-but suggests adaptations to reflect changes in the concept of quality over the past 15years. The application of the updated framework is presented in a case study, which uses it to measure and inform quality improvements in northern Nigeria across the reproductive, maternal, newborn, and child health continuum of care. Data from 231 sampled basic and comprehensive emergency obstetric and newborn care (BEmONC and CEmONC) facilities in six northern Nigerian states showed that only 35%-47% of facilities met minimum quality standards in infrastructure. Standards for human resources performed better with 49%-73% reaching minimum standards. A framework like this could form the basis for a certification scheme. Certification offers a practical and concrete opportunity to drive quality standards up and reward good performance. It also offers a mechanism to strengthen accountability.

Access to comprehensive emergency obstetric and newborn care facilities in three rural districts of Sindh province, Pakistan.

BackgroundPakistan’s maternal and child health indicators remain unacceptably high, with a maternal mortality ratio of 276 per 100,000 live births and a neonatal mortality rate of 55 per 1,000 live births. Provision of basic and comprehensive emergency obstetric and newborn care is mandated by the government; however, coverage, access, and utilisation levels remain unsatisfactory, with the situation in Sindh province being amongst the worst in the country. This study attempted to assess access to comprehensive emergency obstetric and newborn care (C-EmONC) facilities and barriers hampering access in Sindh.MethodsOne public sector hospital in each of three districts in Sindh province providing C-EmONC services were selected for a facility exit survey. A cross-sectional household survey and focus group discussions were conducted in the catchment population of these hospitals.ResultsOverall, 82% and 96% of those who utilised a public or private C-EmONC facility, respectively, incurred out-of-pocket expenditure. As expected, those living more than 5 km from the facility reported higher mean expenditure than those living within 5 km of the facility. More than half of the respondents (55%) among public sector users and the majority (71%) of private sector users could not afford travel costs. More than one third (35%) of public sector users and about two thirds (64%) of private sector users who could not afford travel costs took loans. The proportion of respondents who took loans was higher among those living more than 5 km of the health facility compared to those living within a 5 km distance. The majority of respondents (70%) in the community survey chose to go to a private sector C-EmONC facility. In addition to poverty, in terms of sociocultural access, religious and ethnic discrimination and the poor attitude of facility staff were amongst the most important barriers to accessing a C-EmONC facility.ConclusionsC-EmONC facilities in both the public and private sectors may simply not be accessible and affordable for the vast majority of poor and marginalised women in targeted districts.

Coverage of emergency obstetric care and availability of services in public and private health facilities in Bangladesh.

To assess the coverage of emergency obstetric care (EmOC) and the availability of obstetric services in Bangladesh. In a national health facility assessment performed between November 2007 and July 2008, all public EmOC facilities and private facilities providing obstetric services in the 64 districts of Bangladesh were mapped. The performance of EmOC services in these facilities during the preceding month was investigated using a semi-structured questionnaire completed through interviews of managers and service providers, and record review. In total, 8.6 (2.1 public and 6.5 private) facilities per 500000 population offered obstetric care services. Population coverage by obstetric care facilities varied by region. Among 281 public facilities designated for comprehensive EmOC, cesarean delivery was available in only 215 (76.5%) and blood transfusion services in 198 (70.5%). In the private sector (for profit and not for profit), these services were available in more than 80% of facilities. In all facility types, performance of assisted vaginal delivery (range 12.2%-48.4%) and use of parenteral anticonvulsants to treat pre-eclampsia/eclampsia (range 48.6%-80.8%) were low. The main reason for non-availability of EmOC services was a lack of specialist/trained providers. Bangladesh needs to increase the availability of EmOC services through innovative public-private partnerships. In the public sector, additional trained manpower supported by an incentivized package should be deployed.

Validating the British Columbia Perinatal Data Registry: a chart re-abstraction study.

BackgroundThe British Columbia Perinatal Data Registry (BCPDR) contains individual-level obstetrical and neonatal medical chart data for virtually all births occurring in British Columbia, Canada. The objective of this study was to assess the validity of information in the BCPDR by performing a provincial chart re-abstraction study.MethodsA two-stage stratified clustered sampling design was employed. Obstetrical facilities were stratified based on geographic location and obstetrical volume. Charts of mothers and newborns with a length of stay of five or more days or transfer to another facility following the delivery were oversampled. A total of 85 maternal and 32 newborn variables were assessed for completeness (percent completion) and validity (sensitivity and specificity for categorical variables, intra-class correlation coefficient [ICC] for continuous variables).Results1,084 maternal and 1,142 newborn charts were abstracted. Mandatory variables such as primary indication for induction and primary indication for cesarean delivery were 100 % complete. Some variables such as pre-pregnancy weight were relatively more complete in the re-abstraction as compared with the BCPDR (83.0 % vs 76.8 %; p < 0.001). The validity of key surveillance variables was high (e.g., HIV screening completed [sensitivity 98.0 %, 95 % confidence interval (CI) 97.0–98.8 %; specificity 72.3 %, 95 % CI 60.8–81.9 %], induction of labour [sensitivity 93.9 %, 95 % CI 90.2–96.5 %; specificity 98.7 %, 95 % CI 97.7–99.3 %], primary elective cesarean delivery [sensitivity 96.0 %, 95 % CI 83.8–99.7 %; specificity 99.8 %, 95 % CI 99.4–100.0 %], gestational age from newborn examination [ICC 0.99, 95 % CI 0.99–0.99]). Examples of variables with lower validity included total admissions prior to delivery episode, maternal smoking status, and timing of breastfeeding initiation.ConclusionMany important clinical and population health variables in the BCPDR had excellent validity. Some key variables warrant strengthening through improved definitions, system changes, and abstractor training.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0563-7) contains supplementary material, which is available to authorized users.

Infection control practices at obstetric care facilities in Madhya Pradesh, India

Infection control practices at obstetric care facilities in Madhya Pradesh, India

Real-world practice of obstetricians in respect of assays for antiphospholipid antibodies

Objective. The international classification criteria (CC) for definite antiphospholipid syndrome (APS) recommend confirmation of the sustained presence, for at least 12 weeks, of both lupus anticoagulant (LA), as determined by aPTT and RVVT, and anti β2glycoprotein I (β2GPI) or anticardiolipin (aCL) IgG and/or IgM. However, it remains unclear whether obstetricians comply with the aforementioned CC for the diagnosis of APS in daily clinical practice. We performed a nationwide survey to examine the attitudes of Japanese obstetricians toward the use of assays for antiphospholipid antibodies (aPLs).Methods. A questionnaire was sent to 2,700 obstetric facilities where maternity checkups are carried out. The types of assays conducted for aPLs, ascertainment of persistence of the antibodies for at least 12 weeks, and the cutoff points used for the assays were examined.Results. Of the facilities surveyed, 61.5% carried out the assay(s) only once. In regard to the type of assay performed, 97.1% carried out the assay for aCL IgG and/or β2GPI-dependent aCL, while 67.9% performed the LA-aPTT and/or LA-RVVT assay. Only 8.8% carried out assays for both LA. As for the cutoff points used, 98% of the facilities used lower cutoff points described in the manufacturers’ manuals rather than the cutoff values recommended in the CC.Conclusion. Thus, only a limited number of facilities adhered precisely to the CC for the diagnosis of APS. Inappropriate treatment and unnecessary expense are potentially major concerns when facilities overdiagnose APS using lower cutoff points or without ascertaining the persistence of the antibodies for at least 12 weeks. On the other hand, some patients miss the opportunity to be treated for APS because of the absence of testing for LA.

Immediate effects of the Fukushima nuclear power plant disaster on depressive symptoms among mothers with infants: a prefectural-wide cross-sectional study from the Fukushima Health Management Survey.

BackgroundMothers of young children are at high-risk for developing adverse mental health effects following a nuclear accident. Using the Japanese pregnancy registration system, the prefecture of Fukushima launched a population-based survey of women who were pregnant at the time of the Fukushima nuclear accident in order to assess their and their newborns’ health. In this paper, we focus on the results of a screen for depressive symptoms among new mothers and its association with geographical region and interruption of obstetrical care after the Fukushima nuclear accident, which occurred after the Great East Japan Earthquake on March 11, 2011.MethodsThe survey targeted women who lived in Fukushima prefecture and who had registered their pregnancies between August 1, 2010 and July 31, 2011. Among the 16,001 women targeted, 9,321 returned the questionnaires (response proportion = 58.3%) and data from 8,196 women with singleton live births were analyzed. The main outcome measure was a standard two-item depression screen. Regional radiation levels were determined from the prefecture’s periodical reports, and interruption in obstetrical care after the Fukushima nuclear accident was determined from mothers’ individual responses to the questionnaire.ResultsAmong the 8,196 women, 2,262 (28%) screened positive for depressive symptoms. After adjusting for maternal and infant characteristics, both mothers in Soso, the region in which the nuclear power plant is located, and mothers that had changed obstetrical care facilities were significantly more likely to screen positive for depression. In contrast, mothers in Iwaki and Aizu, regions with relatively low radiation levels, were significantly less likely to screen positive for depression.ConclusionsOur findings suggest that improving mental health support for mothers with infants should be a high priority in the acute phase of nuclear disaster response. We further recommend that in the strategic provisioning of parental support, close attention should be paid to regional variations in negative mental health consequences, particularly to those who experienced an interruption in their obstetrical care.

Determinants of delays in travelling to an emergency obstetric care facility in Herat, Afghanistan: an analysis of cross-sectional survey data and spatial modelling.

BackgroundWomen’s delays in reaching emergency obstetric care (EmOC) facilities contribute to high maternal and perinatal mortality and morbidity in low-income countries, yet few studies have quantified travel times to EmOC and examined delays systematically. We defined a delay as the difference between a woman’s travel time to EmOC and the optimal travel time under the best case scenario. The objectives were to model travel times to EmOC and identify factors explaining delays. i.e., the difference between empirical and modelled travel times.MethodsA cost-distance approach in a raster-based geographic information system (GIS) was used for modelling travel times. Empirical data were obtained during a cross-sectional survey among women admitted in a life-threatening condition to the maternity ward of Herat Regional Hospital in Afghanistan from 2007 to 2008. Multivariable linear regression was used to identify the determinants of the log of delay.ResultsAmongst 402 women, 82 (20%) had no delay. The median modelled travel time, reported travel time, and delay were 1.0 hour [Q1-Q3: 0.6, 2.2], 3.6 hours [Q1-Q3: 1.0, 12.0], and 2.0 hours [Q1-Q3: 0.1, 9.2], respectively. The adjusted ratio (AR) of a delay of the “one-referral” group to the “self-referral” group was 4.9 [95% confidence interval (CI): 3.8-6.3]. Difficulties obtaining transportation explained some delay [AR 2.1 compared to “no difficulty”; 95% CI: 1.5-3.1]. A husband’s very large social network (> = 5 people) doubled a delay [95% CI: 1.1-3.7] compared to a moderate (3-4 people) network. Women with severe infections had a delay 2.6 times longer than those with postpartum haemorrhage (PPH) [95% CI: 1.4-4.9].ConclusionsDelays were mostly explained by the number of health facilities visited. A husband’s large social network contributed to a delay. A complication with dramatic symptoms (e.g. PPH) shortened a delay while complications with less-alarming symptoms (e.g. severe infection) prolonged it. In-depth investigations are needed to clarify whether time is spent appropriately at lower-level facilities. Community members need to be sensitised to the signs and symptoms of obstetric complications and the urgency associated with them. Health-enhancing behaviours such as birth plans should be promoted in communities.

Assessing post-abortion care in health facilities in Afghanistan: a cross-sectional study.

BackgroundComplications of abortion are one of the leading causes of maternal mortality worldwide, along with hemorrhage, sepsis, and hypertensive diseases of pregnancy. In Afghanistan little data exist on the capacity of the health system to provide post-abortion care (PAC). This paper presents findings from a national emergency obstetric and neonatal care needs assessment related to PAC, with the aim of providing insight into the current situation and recommendations for improvement of PAC services.MethodsA national Emergency Obstetric and Neonatal Care Needs Assessment was conducted from December 2009 through February 2010 at 78 of the 127 facilities designated to provide emergency obstetric and neonatal care services in Afghanistan. Research tools were adapted from the Averting Maternal Death and Disability Program Needs Assessment Toolkit and national midwifery education assessment tools. Descriptive statistics were used to summarize facility characteristics, and linear regression models were used to assess the factors associated with providers’ PAC knowledge and skills.ResultsThe average number of women receiving PAC in the past year in each facility was 244, with no significant difference across facility types. All facilities had at least one staff member who provided PAC services. Overall, 70% of providers reported having been trained in PAC and 68% felt confident in their ability to perform these services. On average, providers were able to identify 66% of the most common complications of unsafe or incomplete abortion and 57% of the steps to take in examining and managing women with these complications. Providers correctly demonstrated an average of 31% of the tasks required for PAC during a simulated procedure. Training was significantly associated with PAC knowledge and skills in multivariate regression models, but other provider and facility characteristics were not.ConclusionsWhile designated emergency obstetric facilities in Afghanistan generally have most supplies and equipment for PAC, the capacity of healthcare providers to deliver PAC is limited. Therefore, we strongly recommend training all skilled birth attendants in PAC services. In addition, a PAC training package should be integrated into pre-service medical education.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0439-x) contains supplementary material, which is available to authorized users.

Current Status of the Screening of Chlamydia trachomatis Infection Among Japanese Pregnant Women.

Chlamydia trachomatis (CT) infection in pregnancy can cause maternal disease, adverse pregnancy outcomes, and neonatal disease [1-6]. In general, approximately 80% of CT infected women are asymptomatic or minimally symptomatic. There-fore, screening is the only means to effectively identify infec-tions [2]. In Japan, pregnant women are routinely tested for CT with the Japanese public funds. According to the guide-lines for obstetrical practice in Japan [7], Japanese obstetri-cians must provide a test for the detection of CT for the pre-vention of neonatal CT infection and diagnose urogenital CT infection when CT is detected using polymerase chain reac-tion (PCR), strand displacement amplification, transcription mediated amplification, an enzyme immunoassay, or culture methods in specimens obtained from the uterine cervix (CT nucleic acid detection tests). However, CT antibody detection by IgA tests has been substituted for these methods by some of obstetricians.On October 2014, we requested 2,544 obstetrical facilities that are members of Japan Association of Obstetricians and Gynecologists (JAOG) to provide information of CT screen-ing tests in pregnant women between October 2013 and March 2014. A total of 1,644 (64.6%) of 2,544 obstetrical facilities responded with possible statistical analysis information on a total of 328,788 women, accounting for approximately 65% of all deliveries that occurred in Japan during the study period. Of the 1,644 obstetrical facilities, CT nucleic acid detection PCR tests, CT nucleic acid detection tests except PCR and CT antibody detection tests were performed in 1,221 (74.3%), 408 (24.8%) and 15 (0.9%) facilities, respectively.Table 1 shows the maternal age distribution under the three CT screening tests (CT nucleic acid detection tests with and without PCR and CT antibody detection tests). There were no significant differences in the maternal age distribution among the three CT screening tests groups.Table 2 shows the results of CT screening tests (CT nucle-ic acid detection tests with and without PCR and CT antibody detection tests) of the study population by age. There were no significant differences in the rate of positive CT between the two groups of CT nucleic acid detection screening tests with and without PCR. However, the positive rate by the CT anti-body detection tests was significantly higher than those by the two CT nucleic acid detection tests with and without PCR (P < 0.01 by X

The Japan Environment and Children's Study (JECS): A Preliminary Report on Selected Characteristics of Approximately 10 000 Pregnant Women Recruited During the First Year of the Study.

BackgroundThe Japan Environment and Children’s Study (JECS) is an ongoing nationwide birth cohort study launched in January 2011. In this progress report, we present data collected in the first year to summarize selected maternal and infant characteristics.MethodsIn the 15 Regional Centers located throughout Japan, the expectant mothers were recruited in early pregnancy at obstetric facilities and/or at local government offices issuing pregnancy journals. Self-administered questionnaires were distributed to the women during their first trimester and then again during the second or third trimester to obtain information on demographic factors, physical and mental health, lifestyle, occupation, environmental exposure, dwelling conditions, and socioeconomic status. Information was obtained from medical records in the first trimester and after delivery on medical history, including gravidity and related complications, parity, maternal anthropometry, and infant physical examinations.ResultsWe collected data on a total of 9819 expectant mothers (mean age = 31.0 years) who gave birth during 2011. There were 9635 live births. The selected infant characteristics (singleton births, gestational age at birth, sex, birth weight) in the JECS population were similar to those in national survey data on the Japanese general population.ConclusionsOur final birth data will eventually be used to evaluate the national representativeness of the JECS population. We hope the JECS will provide valuable information on the impact of the environment in which our children live on their health and development.

Prevalence of human T-cell leukemia virus type 1 carrier in Japanese pregnant women in 2013.

Since September 2010, in Japan serological screening for the detection of human T-cell leukemia virus type 1 (HTLV-1) antibodies can be performed for all women during pregnancy with the Japanese public funds for strategies for prevention of HTLV-1 vertical transmission, because Japan, especially Kyushu area, has been reported to be one of the areas of highest prevalence of HTLV-1 in the world [1, 2]. In our previous study [3], we examined the prevalence of HTLV-1 carrier in Japanese pregnant women according to the implement rate and results of HTLV-1 screening and confirmation tests of women who gave births in Japan in 2011. The total rates of positive HTLV-1 screening tests and positive western blot (WB) test in positive screening tests were 0.32% and 49.8%, respectively in 2011. Considering the response rate and the rate of implementation of WB test, the number of HTLV-1 carrier in Japanese pregnant women in 2011 was estimated to be 1,560 (0.15%). In addition, although the number of delivery in Kyushu area was only 14% of Japanese deliveries, 53% of HTLV-1 carrier of Japanese pregnant women was present in Kyushu area. Recently, the migration of Japanese people from Kyushu area to the metropolitan areas has been thought to contribute to a significant decrease of HTLV-1 carriers in Kyushu area and an increase in Kanto (including Tokyo) area in Japan [1, 4]. To confirm this migration in Japanese pregnant women, on December 2014, we requested again 2,544 obstetrical facilities that are members of Japan Association of Obstetricians and Gynecologists (JAOG) to provide information of HTLV-1 tests in pregnant women who delivered at ≥ 22 weeks’ gestation in 2013. A total of 1,356 (53.3%) of 2,544 obstetrical facilities responded and information on a total of 538,167 women, accounting for approximately 54% of all deliveries that occurred in Japan during the study period (approximately 1,001,800 births) was provided. In 2013, the total rates of positive HTLV-1 screening tests and positive WB test in positive screening tests were 0.35% and 50.8%, respectively. Considering the response rate and the rate of implementation of WB test, the number of HTLV-1 carrier in Japanese pregnant women in 2013 was estimated to be 1,780 (0.18%). Table 1 shows the difference in the estimated number of HTLV-1 carrier based on positive WB test by area in Japan between 2011 and 2013. The estimated number of HTLV-1 carrier in 2013 seemed to be more than that in 2011, especially in the northeast and southwest (Kyushu) areas. In addition, 51% of HTLV-1 carrier of Japanese pregnant women was present in Kyushu area, although the number of delivery in Kyushu area was only 13% of Japanese deliveries in 2013. Although the migration of Japanese people from Kyushu area to the metropolitan areas has been supposed to contribute to a significant decrease of HTLV-1 carriers in Kyushu area, the estimated number of HTLV-1 carrier of pregnant women seemed to be increased in Kyushu area. In addition, the estimated rate of HTLV-1 carrier in pregnant women in Kyushu area was still significantly higher than that in the other areas (P < 0.01 by the Chi-square test). Therefore, there are still remaining problems concerning the locality for strategies for prevention of HTLV-1 vertical transmission in Japan.

Current Status of the Nutritional Guidance of Baby to Human T-Cell Leukemia/Lymphoma Virus Type I Carriers by Japanese Obstetricians

In humans, breast-feeding is the major route for mother-tochild transmission of human T-cell leukemia/lymphoma virus type I (HTLV-I). HTLV-I transmission by breast milk is associated with ingestion of infected cells and can be prevented by formula-feeding [1]. Therefore, in most of the developed world, mothers with a proven HTLV-I infection should be advised not to breast-feed their babies. In our recent observation in Japan, the number of HTLV-1 carrier in Japanese pregnant women has been estimated to be 1,620 (0.16% of all pregnant women) per year [2]. Based on the guidelines for obstetrical practice in Japan, the HTLV-1 carrier should be recommended to be instructed in the following methods as alternatives to breast-feeding for the prevention of HTLV-1 vertical transmission: 1) formula feeding, 2) frozen-thawed breast milk and 3) short-term breast-feeding within the first 3 months after birth [3]. However, the current status of the nutritional guidance of baby to HTLV-1 carriers by Japanese obstetricians has not been well examined. To examine the current status of mother-to-child transmission of HTLV-I preventing in Japan, on December 2014, we requested 2,544 obstetricians that are members of Japan Association of Obstetricians and Gynecologists (JAOG) and directors of each obstetric facility to provide information of the strategies. Of the 2,544 obstetricians, 1,345 (52.9%) responded. In cases of pregnant woman with positive western blot (WB) test, 953 (70.9%) of the Japanese obstetricians perform the informed choice of the three methods described above, 337 (25.1%) recommend formula feeding, and six (0.4%) recommend long-term breast milk, respectively. In Japan, because the mother-to-child transmission rates under the above three methods have been reported to be both about 3% [4, 5], about 70% of Japanese obstetricians perform the informed choice of the three methods as alternatives to breast-feeding. Breastfeeding is beneficial to the health of both the infant and mother, and mothers generally believe this. Therefore, it is possible that many of the HTLV-I-carrier mothers want to choose breastfeeding as the method of feeding their infants. However, the ground studies for the transmission rates with frozen-thawed breast milk and short-term breast-feeding have not been large (n = 64 and 162 in cases of frozen-thawed breast milk and short-term breast-feeding, respectively) [4]. Therefore, we have not yet evaluated the utility of these methods precisely. It is necessary to clarify the issues by follow-up of all cases prospectively. On the other hand, it has been described that the diagnosis of HTLV-1 carriers in their children is possible at the age of ≥ 3. However, only 698 obstetricians (55.4%) of them recommend the HTLV-1 screening tests for the children of women with positive WB test when they become ≥ 3 years old. The HTLV-1 screening tests might fraught with problems of announcements and personal information; however, the results are possible to facilitate the future diagnosis of adult T-cell leukemia and HTLV-1 associated myelopathy. Therefore, it seems to be necessary to convey to the mothers about the diagnostic methods of the HTLV-1 carriers of their children. These problems will be expected to be elucidated by a nationwide prospective cohort study.

Selection and concentration of obstetric facilities in Japan: Longitudinal study based on national census data.

A shortage of obstetricians with increased workload is a social problem in Japan. In response, the government and professional bodies have accelerated the 'selection and concentration' of obstetric facilities. The aim of this study was to evaluate the recent trend of selection and concentration. We used data on the number of deliveries and of obstetricians in each hospital and clinic in Japan, according to the Static Survey of Medical Institutions in 2005, 2008 and 2011. To evaluate the inter-facility equality of distribution of the number of deliveries, number of obstetricians and number of deliveries per obstetrician, Gini coefficients were calculated. The number of obstetric hospitals decreased by 20% and the number of deliveries per hospital increased by 26% between 2005 and 2011. Hospital obstetricians increased by 16% and the average number of obstetricians per hospital increased by 19% between 2008 and 2011. Gini coefficient of deliveries has significantly decreased. In contrast, Gini coefficient of deliveries per obstetrician has significantly increased. The degree of increase in obstetricians and of decrease in deliveries per obstetrician was largest at the hospitals with the highest proportion of cesarean sections. The proportion of obstetric hospitals with the optimal volume of deliveries and obstetricians, as defined by Japan Society of Obstetrics and Gynecology, was 4% in 2008, and it had doubled to 8.1% 3 years later. The selection and concentration of obstetric facilities is progressing rapidly and effectively in Japan.

Where do the rural poor deliver when high coverage of health facility delivery is achieved? Findings from a community and hospital survey in Tanzania.

IntroductionAs part of maternal mortality reducing strategies, coverage of delivery care among sub-Saharan African rural poor will improve, with a range of facilities providing services. Whether high coverage will benefit all socio-economic groups is unknown. Iringa rural District, Southern Tanzania, with high facility delivery coverage, offers a paradigm to address this question. Delivery services are available in first-line facilities (dispensaries, health centres) and one hospital. We assessed whether all socio-economic groups access the only comprehensive emergency obstetric care facility equally, and surveyed existing delivery services.MethodsDistrict population characteristics were obtained from a household community survey (n = 463). A Hospital survey collected data on women who delivered in this facility (n = 1072). Principal component analysis on household assets was used to assess socio-economic status. Hospital population socio-demographic characteristics were compared to District population using multivariable logistic regression. Deliveries' distribution in District facilities and staffing were analysed using routine data.ResultsWomen from the hospital compared to the District population were more likely to be wealthier. Adjusted odds ratio of hospital delivery increased progressively across socio-economic groups, from 1.73 for the poorer (p = 0.0031) to 4.53 (p<0.0001) for the richest. Remarkable dispersion of deliveries and poor staffing were found. In 2012, 5505/7645 (72%) institutional deliveries took place in 68 first-line facilities, the remaining in the hospital. 56/68 (67.6%) first-line facilities reported ≤100 deliveries/year, attending 33% of deliveries. Insufficient numbers of skilled birth attendants were found in 42.9% of facilities.DiscussionPoorer women remain disadvantaged in high coverage, as they access lower level facilities and are under-represented where life-saving transfusions and caesarean sections are available. Tackling the challenges posed by low caseloads and staffing on first-line rural care requires confronting a dilemma between coverage and quality. Reducing number of delivery sites is recommended to improve quality and equity of care.

Introduction of Routine Obstetric Ultrasound in an Urban Health Center: Results and Benefits

Background Maternal mortality ratio (MMR) in India is 200/100,000 live births, many of which are preventable. To reduce MMR, the Government of India has set up basic obstetric ultrasonography facilities in primary health centers. This service was introduced in a nurse-run, low-risk antenatal and delivery service in an urban health center. This report documents the benefit of prenatal ultrasound in an urban health center. Methods This is a retrospective observational study carried out in an urban health center of a tertiary medical college and hospital, which provides health services to the economically disadvantaged urban population. The urban health center runs a nurse-led low-risk antenatal and delivery service. All consecutive antenatal ultrasounds from March 2012 to February 2013 were analyzed. Routine obstetric ultrasound was done for all women at their booking visit. Crown-rump length was measured if the first visit was prior to 13 weeks of gestation. If they presented after 13 weeks of gestation, biparietal diameter and femur length were measured to confirm gestational age. Results A total of 715 obstetric ultrasounds were performed during the period from 2012 to 2013. Among the 715 ultrasounds, 71.6% were for estimation of gestational age and 15.7% were for amniotic fluid index estimation for fetal surveillance. Among the dating ultrasounds performed, 48.6% were for primigravida women and 51.4% were for multigravida women. Discrepancies were identified in the expected date of confinement by the last menstrual period in 26% of the dating ultrasounds and 4.2% of women were identified to have a missed abortion at booking visit. Conclusion Maternal morbidity and mortality can be reduced by early detection of missed abortion, placenta previa, twin pregnancy, and molar pregnancy by routine obstetric ultrasound at booking visit. Routine obstetric ultrasound at the first and second trimesters had obvious benefits in confirming the expected date of delivery in a community where remembering the last menstrual period was not a priority. Introduction of this procedure helped in appropriate management of post-term pregnancies.

Nationwide survey of mother-to-child infections in Japan.

The aim of this survey study was to evaluate a state of mother-to-child infections in Japan. A nationwide survey on 2714 obstetric facilities where regular maternity checkups were carried out was conducted. A primary questionnaire assessed numbers of pregnancies including induced abortion, spontaneous abortion, still-birth as well as live-birth, which were affected by congenital infections of 6 pathogens during a year of 2011. The secondary questionnaire assessed clinical information, diagnostic modality, and the outcome for each case. The clinical features and diagnostic problems were evaluated. The high reply rates for the primary (73.7%) and the secondary questionnaire (100%) were achieved. The presence of congenital infections for 34 cases with cytomegalovirus (CMV), 1 with Toxoplasma gondii, 4 with rubella virus, 5 with Treponema pallidum, 8 with herpes simplex virus, and 69 with parvovirus B19 was confirmed after questionnaire assessment. The incidence of fetal demise among pregnancies with congenital parvovirus B19 infection was up to 71.0%. Eleven mothers with hydrops fetalis received prenatal fetal therapies involving fetal blood transfusion and immunoglobulin administration, whereas only three pregnancies (27.3%) ended in live-births. This survey study for the first time revealed the annual frequency of pregnancies with mother-to-child infections of 6 pathogens in Japan. The results involve important information and are helpful for clinical practitioners. The majority of neonates with congenital infection of CMV or T. gondii might be undiagnosed in obstetric facilities.

Patterns of use of a maternal mental health service in a low-resource antenatal setting in South Africa.

The prevalence of perinatal common mental disorders in South Africa is high, yet little is known about mental health service use among pregnant and postnatal women. This paper reports on pregnant women's patterns of use of a counselling service at a primary level obstetric facility in Cape Town, South Africa, between January 2010 and December 2011. It investigates whether these are associated with demographics, severity and risk of depressive symptoms. Participants (N = 3311) were screened for psychological distress using the Edinburgh Postnatal Depression Scale (EPDS) at their first antenatal visit. Risk factors for antenatal depression were assessed using a 11-item checklist. Questionnaires were self-administered, but some participants required assistance. Participants scoring positive (≥13) on the EPDS were offered referral to on-site, individual counselling, and assigned to one of three groups according to their service use: declined referral; accepted referral and attended counselling sessions; and accepted referral but defaulted all appointments. Consent to participate was received by 3437 (96.4%) participants who were offered screening, of which 627 (18.9%) screened positive on the EPDS. Of these, 363 (57.9%) attended counselling. Both bivariate analyses and regression analyses revealed that age and risk factor assessment score were associated with screening positive on the EPDS. Odds ratios (OR) for accepting counselling were OR = 0.94 (95% CI = 0.92-0.97) for gestation, OR = 1.27 (95% CI = 1.15-1.39) for EPDS score and OR = 0.48 (95% CI = 0.23-0.99) for reporting three or more risk factors. OR for attending counselling were, for age: OR = 1.06 (95% CI = 1.00-1.12) and for reporting three or more risk factors: OR = 0.60 (95% CI = 0.37-0.97). While the majority of women with psychological distress accessed the counselling service provided, strategies to increase service use of younger pregnant women specifically are required.

Evidence from facility level inputs to improve quality of care for maternal and newborn health: interventions and findings.

Most of the maternal and newborn deaths occur at birth or within 24 hours of birth. Therefore, essential lifesaving interventions need to be delivered at basic or comprehensive emergency obstetric care facilities. Facilities provide complex interventions including advice on referrals, post discharge care, long-term management of chronic conditions along with staff training, managerial and administrative support to other facilities. This paper reviews the effectiveness of facility level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined facility level interventions and included 32 systematic reviews.Findings suggest that additional social support during pregnancy and labour significantly decreased the risk of antenatal hospital admission, intrapartum analgesia, dissatisfaction, labour duration, cesarean delivery and instrumental vaginal birth. However, it did not have any impact on pregnancy outcomes. Continued midwifery care from early pregnancy to postpartum period was associated with reduced medical procedures during labour and shorter length of stay. Facility based stress training and management interventions to maintain well performing and motivated workforce, significantly reduced job stress and improved job satisfaction while the interventions tailored to address identified barriers to change improved the desired practice. We found limited and inconclusive evidence for the impacts of physical environment, exit interviews and organizational culture modifications.At the facility level, specialized midwifery teams and social support during pregnancy and labour have demonstrated conclusive benefits in improving maternal newborn health outcomes. However, the generalizability of these findings is limited to high income countries. Future programs in resource limited settings should utilize these findings to implement relevant interventions tailored to their needs.

Current human T‐cell lymphotropic virus type 1 mother‐to‐child transmission prevention status in Kagoshima

The aim of this study was to assess the current human T-cell lymphotropic virus type 1 (HTLV-I) mother-to-child transmission (MTCT) prevention system in Kagoshima Prefecture. We investigated the rate of carrier pregnant women from obstetrics facilities in Kagoshima by mail in 2012 and compared our results with previous study results. We interviewed carrier pregnant women about their choices for infant nutrition, and we interviewed midwives about the follow-up system. In 2012, 8719 screening tests were performed, covering 58.1% of all pregnant women in Kagoshima; the rate of carrier pregnant women was 1.3%. Of 59 carriers, 39 chose short-term breast-feeding. The HTLV-I carrier rate among pregnant women in Kagoshima has declined. The current HTLV-I MTCT prevention system in Kagoshima is effective, but not sufficient. To bring the nutrition methods to completion, various types of support are needed. Further studies will elucidate many unsolved problems concerning MTCT.