Obstetric Facilities Research Articles

Current status of Neisseria gonorrhoeae cervicitis in pregnant women in Japan.

We evaluated the current prevalence of gonococcal cervicitis among pregnant women in institutes that either do or do not routinely screen for gonococcal infection in Japan. We requested 2,330 obstetrical facilities to provide information on Neisseria gonorrhoeae cervicitis in pregnant women. A total of 1,876 (80.5%) of them responded. The universal screening test for gonococcal cervicitis, involving nucleic acid amplification for all pregnant women, was performed in 281 institutes (13.9% of institutes across Japan). The total rate of pregnant women with gonococcal cervicitis was 1.3% in the institutes performing the screening test during pregnancy, while it was only 0.2% (p < 0.01) in those not performing it. This suggests that 84% of infected women may have been missed in the institutes that do not routinely perform the screening test for gonococcal cervicitis. It may be time to examine the cost-effectiveness of providing gonococcal screening for all pregnant women in Japan.

Outcomes of 'one-day trial of vaginal delivery of twins' at 36-37 weeks' gestation in Japan.

ObjectiveThe lack of obstetricians in Japan has prevented the implementation of a 24–hour delivery monitoring system for high-risk deliveries such as twin vaginal delivery at many obstetric facilities. To examine the outcomes of a 1-day trial of the vaginal delivery of twins at 36–37 weeks' gestation.MethodsWe induced the vaginal delivery of twins at 36–37 weeks' gestation of 256 women who provided consent between January 2007 and December 2016 using the following protocol: 1) administration of 0.5 mg oral prostaglandin E2 every 1 hour (maximum: 1.5 mg) in the morning; 2) intravenous administration of oxytocin and amniotomy in the afternoon; and 3) selection of caesarean delivery when vaginal delivery was not expected by evening. We examined their perinatal outcomes in a chart review.ResultsThe completion rates of vaginal delivery in total, nulliparous, and multiparous women were 79%, 72%, and 84%, respectively. There were no cases of neonatal asphyxia. The total incidence of neonatal respiratory disorders was 2.1%, but there were no cases of persistent pulmonary hypertension. The total incidence of postpartum hemorrhage requiring transfusion was 2.7%.ConclusionThe 1-day planned vaginal delivery of twins at 36–37 weeks' gestation appears valid and safe, and our findings suggest that it can be an option for the delivery of twins.

The Jehovah's Witness obstetric patient - a literature review.

The patient's right to refuse blood transfusion must be honoured in case of its clear expression. Some special pharmacologic and/or surgical procedures can be useful in a Jehovah Witness (JW) parturient. In case of excess blood loss the maintenance of peripheral tissue oxygenation is crucial. Only a few hospitals have equipment for blood salvage, and alternative oxygen carriers have potentially lethal side effects. Findings suggest that obstetric facilities should develop special algo-rithms of management in the case of the JW obstetric patient, with written declaration of which elements of blood are not acceptable for the patient, early diagnosis and intensive treatment of anaemia in pregnancy, administration of antifibrinolytic agents before surgery, use of electric surgical tools to restore haemostasis, early detection and aggressive treatment of excessive blood loss and, last but not least, close cooperation between obstetricians and anaesthesiologists, including sharing the information about the patient's refusal of blood transfusion.

CONOCIMIENTOS DEL PERSONAL DE ENFERMERÍA SOBRE LACTANCIA MATERNA

Objetivo: el objetivo fue identificar los conocimientos que tiene el personal de enfermeria sobre la lactancia materna (LM) en un servicio de obstetricia, durante el ano 2016. Metodologia: estudio transversal descriptivo. Muestra conformada por la totalidad del personal de enfermeria (n: 71) en el area de obstetricia. Se utilizo una encuesta con variables sociodemograficas y de conocimientos; estas ultimas construidas a partir del documento por la OMS para formacion de personal de salud. El instrumento tuvo evaluacion de dos expertos. Los conocimientos analizados fueron: bases anatomicas y fisiologicas, manejo de las afecciones del pecho, razones medicas aceptables para el uso de sucedaneos, diez pasos hacia una LM exitosa y como ayudar a la madre. A las variables cuantitativas se les hallo medidas de tendencia central, a las variables cualitativas se les calculo las frecuencias absolutas y relativas. Resultados: El porcentaje de respuesta correctas en 4 de los 5 factores evaluados estuvo por debajo del 50%: el promedio de conocimientos de bases anatomicas y fisiologicas fue 29,3%, manejo de las afecciones del pecho 43%, razones medicas aceptables para el uso de sucedaneos 21,8%, diez pasos hacia una LM exitosa 75,8% y como ayudar a la madre para lograr la LM 35,2 %. Conclusion: se requiere claridad en conceptos de LM, que permita ser asertivos en la educacion que se brinda a las madres lactantes.

Implementation of the first breastfeeding in Warsaw's maternity hospitals.

Introduction: Birth is associated with the loss of the comfortable intrauterine environment and the beginning of life in the external environment. The newborn undertakes basic life functions in an environment of stimuli to which his nervous system is particularly sensitive. Some fundamental methods that facilitate adaptation to extrauterine life are skin-to-skin contact and the first breastfeeding. Aim: The aim of the study was to assess the provision of the first breastfeeding after natural delivery in Warsaw's medical facilities. Material and method: The method of direct observation was used in the study. The research material was collected using the authored observation sheet designed for the purposes of the study. The tests were carried out in 11 Warsaw obstetric facilities with varying degrees of referentiality, in which the management agreed to conduct the study. It was ensured that the data collected would be presented anonymously. The research began in January 2016 and was completed in December 2017. Results: During the direct contact of the mother with the child, in 97.37% of the cases the newborn was attached to the mother's breast. In 25.01% of the cases, the duration of the first breastfeeding was over 30 minutes, and in the same number of feedings it ranged from 21-30 minutes. The shortest duration of feeding from 1-5 minutes was observed in 5.58% of the cases. Conclusions: In most cases, the first breastfeeding took place within 2 hours of birth. The initiation of breastfeeding after natural delivery took place during the mother's first contact with the child. In more than half of the cases, the first feeding lasted as long as the specialists recommend - over 20 minutes.

Reasons for obstetric referrals from community facilities to a tertiary obstetric facility: A study from Southern Karnataka.

Context:Pregnancy-related preventable morbidity and mortality remain high in India. Safe delivery services should focus on improving neonatal and maternal outcomes while also enabling a positive childbirth experience. However, high rates of intrapartum obstetric referrals are common.Objective:To describe the timing and the reasons for obstetric referrals to a public tertiary care hospital in Bangalore and characteristics of the referring facilities.Methods:We interviewed 320 women who delivered at the tertiary care hospital within a one-month time frame prior to the interview and who originally planned to deliver elsewhere.Results:Ninety four percent of women in the study reported that the decision to transfer to the tertiary hospital was made after the onset of labour. Referrals were made for medical as well as non-medical reasons. About a third (35%) had to take loans to cover the expenses of childbirth.Conclusions:Referrals frequently occurred after the onset of labour. Our data imply that improving obstetric referral protocols will improve the birth experience and reduce the burden on tertiary care facilities and on the women themselves.

Efforts to alter the trajectory of neonatal mortality in Malawi: evaluating relative effects of access to maternal care services and birth history risk factors.

BackgroundThe neonatal mortality rate (NMR) in Malawi has remained stagnant at around 27 per 1000 live births over the last 15 years, despite an increase in the uptake of targeted health care interventions. We used the nationally representative 2015/16 Demographic Health Survey data set to evaluate the effect of two types of maternal exposures, namely, lack of access to maternal or intra-partum care services and birth history factors, on the risk of neonatal mortality.MethodsA causal inference approach was used to estimate a population attributable risk parameter for each exposure, adjusting for co-exposures and household, maternal and child-specific covariates. The maternal exposures evaluated were unmet family planning needs, less than 4+ antenatal care visits, lack of institutional delivery or skilled birth attendance, having prior neonatal mortality, short (8-24 months) birth interval preceding the index birth, first pregnancy, and two or more pregnancy outcomes within the preceding five years of the survey interview.ResultsWe included 9553 women and their most recent live birth within 3 years of the survey. The sample’s overall neonatal mortality rate was 18.5 per 1000 live births. The adjusted population attributable risk for first pregnancies was 3.9/1000 (P < 0.001), while non-institutional deliveries and the shortest preceding birth interval (8-24 months) each had an attributable risk of 1.3/1000 (Ps = 0.01). Having 2 or more pregnancy outcomes within the last 5 years had an attributable risk of 3/1000 (P = 0.006). Attending less than 4 ANC visits had, a relatively large attributable risk (2.1/1,000), and it was not statistically significant at alpha level 0.05.ConclusionsOur analysis addresses the gap in the literature on evaluating the effect of these exposures on neonatal mortality in Malawi. It also helps inform programs and current efforts such as the Every Newborn Action 2020 Plan. Increasing access to maternal care interventions has an important role to play in changing the trajectory of neonatal mortality, and women who are at an increased risk may not be receiving adequate care. Recent studies indicate an urgent need to assess gaps in service readiness and quality of care at the antenatal and obstetric care facilities.

Genito urinary fistula: a series of 1704 cases

Aims: To review our experience in causes, diagnosis and basic principles of surgical treatment of urogenital fistulas.&#x0D; Methods: A retrospective study of 1704 patients with different types of urogenital fistulas were reviewed between October 1995 to October 2018. They were analyzed with regard to age, parity, casual factor, mode of treatment and outcome. Patients were also evaluated at two or three weeks initially, three monthly and later depending upon symptoms.&#x0D; Results: We reviewed our series of female urogenital fistulas that have been treated over a 22 years period. Out of these 1704 cases 864 (62.44%) were Vesico vaginal fistulas, 432 (25.35%) were Urethro vaginal fistulas and 188 (12.2%) were Uretero vaginal. Majority of the patients were young in child bearing age between 16 and 30 years of age, although age range was wide i.e., 11 to 50 years. The most common cause of urogenital fistulas were Obstetrical trauma due to obstructed labor in 400(37.59%) &amp; Gynecological (hysterectomy 180(18.79%) &amp; caesarian section in 72 (6.77%). Patients of Uretero vaginal fistulas were mainly due to unrecognized ureteral injuries during Gynecological procedures (hysterectomy in 136 cases &amp; caesarian section in 10 cases. For repair of vesico vaginal fistulas Transvaginal route for repair was used in 424(39.84%) patients, while Thans abdominal route for repair was used in 560 (52.63%) patients. There were 32 (12.03%) failures in Vesico vaginal fistulas with a success rate of 88%. Mean Hospital stay was 15+ 3.5 days (range 4-30 days) and a mean follow-up of 8+ 3.2 months (range 4 months to 2 years).&#x0D; Conclusions: Management of Urogenital fistulas are among the most distressing complications of obstetric and gynecologic procedures. The patients suffer physically, emotionally and socially. The lack of skilled supervision and adequate obstetric emergency facilities are to blame.

Impact of results-based financing on effective obstetric care coverage: evidence from a quasi-experimental study in Malawi

BackgroundResults-based financing (RBF) describes health system approaches addressing both service quality and use. Effective coverage is a metric measuring progress towards universal health coverage (UHC). Although considered a means towards achieving UHC in settings with weak health financing modalities, the impact of RBF on effective coverage has not been explicitly studied.MethodsMalawi introduced the Results-Based Financing For Maternal and Neonatal Health (RBF4MNH) Initiative in 2013 to improve quality of maternal and newborn health services at emergency obstetric care facilities. Using a quasi-experimental design, we examined the impact of the RBF4MNH on both crude and effective coverage of pregnant women across four districts during the two years following implementation.ResultsThere was no effect on crude coverage. With a larger proportion of women in intervention areas receiving more effective care over time, the overall net increase in effective coverage was 7.1%-points (p = 0.07). The strongest impact on effective coverage (31.0%-point increase, p = 0.02) occurred only at lower cut-off level (60% of maximum score) of obstetric care effectiveness. Design-specific and wider health system factors likely limited the program’s potential to produce stronger effects.ConclusionThe RBF4MNH improved effective coverage of pregnant women and seems to be a promising reform approach towards reaching UHC. Given the short study period, the full potential of the current RBF scheme has likely not yet been reached.

Utility and limitations of perimortem cesarean section: A nationwide survey in Japan

Perimortem cesarean section (PCS) is a procedure performed as part of cardiopulmonary resuscitation (CPR). This study aims to clarify maternal and neonatal prognosis and establish PCS's utility and limitations. We sent structured questionnaires to obstetrics facilities regarding the cases of PCS performed in Japan between April 2010 and April 2015. Receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values of the time from cardiopulmonary arrest (CPA) to return of spontaneous circulation to predict the onset of disseminated intravascular coagulation (DIC). PCS was performed for 18 patients. Out of 18 patients, 12 were resuscitated. The women who were discharged without major sequelae (n = 6) were compared with the non-discharged women who were dead or in persistent vegetative state (n = 12), and median interval time from arrest to PCS was significantly shorter in the former group (P = 0.002). Median interval time from CPA to PCS in the cases in which the neonates survived without major morbidities was significantly shorter than that in the cases of neonatal death and hypoxic encephalopathy (P = 0.01). DIC was observed in 8/9 (89%) patients whose resuscitation took more than 20 min from the diagnosis of CPA. Percutaneous cardiopulmonary support (PCPS) was introduced in 4/9 patients. However, more cases with uncontrolled bleeding, possibly caused by a sudden increase in blood flow and DIC after resuscitation, were observed in the PCPS group compared to the non-PCPS group. PCS can be an effective CPR procedure. However, if PCS is not performed within 20 min from CPA, starting PCPS before PCS is an option.

Implementing Statewide Severe Maternal Morbidity Review: The Illinois Experience.

Severe maternal morbidity (SMM) rates in the United States more than doubled between 1998 and 2010. Advanced maternal age and chronic comorbidities do not completely explain the increase in SMM or how to effectively address it. The Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists have called for facility-level multidisciplinary review of SMM for potential preventability and have issued implementation guidelines. Within Illinois, SMM was identified as any intensive or critical care unit admission and/or 4 or more units of packed red blood cells transfused at any time from conception through 42 days postpartum. All cases meeting this definition were counted during statewide surveillance. Cases were selected for review on the basis of their potential to yield insights into factors contributing to preventable SMM or best practices preventing further morbidity or death. If the SMM review committee deemed a case potentially preventable, it identified specific factors associated with missed opportunities and made actionable recommendations for quality improvement. Approximately 1100 cases of SMM were identified from July 1, 2016, to June 30, 2017, yielding a rate of 76 SMM cases per 10 000 pregnancies. Reviews were conducted on 142 SMM cases. Most SMM cases occurred during delivery hospitalization and more than half were delivered by cesarean section. Hemorrhage was the primary cause of SMM (>50% of the cases). Facility-level SMM review was feasible and acceptable in statewide implementation. States that are planning SMM reviews across obstetric facilities should permit ample time for translation of recommendations to practice. Although continued maternal mortality reviews are valuable, they are not sufficient to address the increasing rates of SMM and maternal death. In-depth multidisciplinary review offers the potential to identify factors associated with SMM and interventions to prevent women from moving along the continuum of severity.

The impact of geographic access on institutional delivery care use in low and middle-income countries: Systematic review and meta-analysis.

BackgroundGeographic access to obstetric care facilities has a significant influence on women’s uptake of institutional delivery care. However, this effect was not consistent across studies. Some studies reported that geographic access to obstetric care facilities had no influence on the use of facility delivery. Therefore, this systematic review and meta-analysis synthesized and pooled the influence of geographic access on institutional delivery service uptake in low and middle-income countries.MethodsMultiple combinations of search terms were used to search articles from six databases and a hand search of reference lists performed. We included observational studies conducted in low and middle-income countries which reported the influence of geographic access on delivery care use. The pooled effects of geographic access on institutional delivery care use were calculated using a random-effects model with a 95% confidence interval.FindingsIn this study a total of 31 studies were included. Among these studies, 15 met criteria for inclusion in the meta-analyses, while the remaining 16 were summarized using qualitative synthesis. Studies included in the analysis where women had to walk 60 minutes or less to access a health facility delivery were significantly heterogeneous. Having access to obstetric care facilities within five kilometres was significantly associated with institutional deliveries (pooled OR = 2.27; 95% CI = 1.82, 2.82). Similarly, a travelling time of 60 minutes or less was significantly associated with higher odds of health facility delivery (pooled OR = 3.30; 95% CI = 1.97, 5.53). Every one-hour and one-kilometre increase in travel time and distance, respectively, was negatively associated with institutional delivery care use.InterpretationGeographic access measured in either physical distance and/or travel time was significantly associated with women’s use of facility delivery. The greater the distance and/or travel time to obstetric care facilities, the greater the barrier and the lesser the service uptake.

Fetal movement frequency and the effect of associated perinatal factors: Multicenter study

BackgroundDecreased fetal movements are associated with adverse perinatal outcomes, including stillbirth. Delayed maternal visits to a health care provider after perceiving decreased fetal movements are frequently observed in stillbirths. Informing pregnant women of the normal range of fetal movement frequency is essential in their earlier visits in order to prevent stillbirth. AimTo investigate the fetal movement frequency in late pregnancy and the effects of associated perinatal factors. MethodsThis prospective multicenter study was conducted in 20 obstetric facilities in our region of Japan. A total of 2337 pregnant women were asked to record the time it took to perceive 10 fetal movements by the modified ‘count to 10’ method every day from 34weeks of gestation until delivery. FindingsThe 90th percentile of the time for the maternal perception of 10 fetal movements was 18–29min, with a gradually increasing trend toward the end of pregnancy. The numbers of both pregnant women giving birth after 39weeks’ gestation and infants with a birth weight exceeding 3000g were significantly higher in mothers who took ≥30min to count 10 fetal movements than in those who took <30min. ConclusionThe maternal perception time of fetal movements shows a gradually increasing trend within 30min for 10 fetal movements by the modified ‘count to 10’ method. Informing pregnant women of the normal range of the fetal movement count time will help improve the maternal recognition of decreased fetal movements, which might prevent fetal death in late pregnancy.

\u2018When helpers hurt\u2019: women\u2019s and midwives\u2019 stories of obstetric violence in state health institutions, Colombo district, Sri Lanka

BackgroundThe paper explores how age, social position or class, and linguistic and cultural background intersect and place women in varying positions of control and vulnerability to obstetric violence in state health institutions in Colombo district, Sri Lanka. Obstetric violence occurs during pregnancy, childbirth and the immediate postpartum period; hence, it is violence that directly affects women. The authors aim to break the traditional culture of silence around obstetric violence and bring attention to the resulting implications for quality of care and patient trust in obstetric care facilities or providers.MethodsFive focus group discussions were held with 28 public health midwives who had prior experience working in labor rooms. Six focus group discussions were held with 38 pregnant women with previous childbirth experience. Additionally, 10 of the 38 women, whom felt they had experienced excessive pain, fear, humiliation, and/or loss of dignity as patients in labor, participated in individual in-depth interviews. An intersectional framework was used to group the qualitative data into categories and themes for analysis.ResultsObstetric violence appears to intersect with systems of power and oppression linked to structural gender, social, linguistic and cultural inequities in Sri Lanka. In our dataset, younger women, poorer women, and women who did not speak Sinhala seemed to experience more obstetric violence than those with relevant social connections and better economic positions. The women in our study rarely reported obstetric violence to legal or institutional authorities, nor within their informal social support networks. Instead, they sought obstetric care, particularly for childbirth, in other state hospitals in subsequent pregnancies.ConclusionsThe quality of obstetric care in Sri Lanka needs improvement. Amongst other initiatives, policies and practices are required to sensitize health providers about the existence of obstetric violence, and repercussions are required for abusive or discriminatory practices. The ethics of care should be further reinforced in the professional training of obstetric health providers.

Peripartum and postpartum outcomes in uncomplicated term pregnancy following ART: a retrospective cohort study from two Italian obstetric units.

STUDY QUESTIONDo singleton uncomplicated term pregnancies conceived by assisted reproductive technology (ART) have adverse peripartum and postpartum outcomes?SUMMARY ANSWERTerm pregnancies following ART, even if uncomplicated until birth, have a higher risk of retained placenta and postpartum hemorrhage (PPH).WHAT IS KNOWN ALREADYThere is consistent evidence that pregnancies following ART have higher incidence of complications during pregnancy. However, few studies specifically investigated birth outcomes in ART term pregnancies.STUDY DESIGN, SIZE, DURATIONA retrospective cohort study was conducted on 14 415 deliveries at two university tertiary care obstetric units. Clinical data were extracted by reviewing obstetric records of all deliveries from 1 January 2010 to 31 December 2014, in a standardized electronic database regarding the mother’s health before and during pregnancy, complications during pregnancy and at birth, and neonatal outcome.PARTICIPANTS/MATERIALS, SETTING, METHODSFollowing an accurate evaluation of exclusion criteria (multiparity, maternal pre-pregnancy diseases, prior uterine surgery, fetal malformations, intrauterine deaths, elective cesarean section and pregnancy complications), the group of uncomplicated singleton term pregnancies from autologous ART conception by in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) (n = 188) was compared with a maternal age and body mass index (BMI) matched group of spontaneous pregnancies (n = 1168). Cases of intrauterine insemination (IUI) (n = 14) and ovulation induction with timed intercourse (n = 18) were not included. Labor, delivery and postpartum outcomes were evaluated. Odds ratios (OR) were adjusted with multivariable logistic regression to maternal age, BMI, nationality and gestational age at birth.MAIN RESULTS AND THE ROLE OF CHANCEThe age of women in the final analysis ranged from 25 to 45 years, while BMI ranged from 17 to 34 kg/m2. Uncomplicated term pregnancies with ART conception had a higher risk of operative delivery (adjusted OR 1.40, 95% confidence interval (CI) 1.01–1.95), retained placenta (adjusted OR 2.63, 95% CI 1.31–5.26) and PPH (adjusted OR 2.86 95% CI 1.37–5.99). Conversely, ART conception did not increase the risk of induced labor (adjusted OR 1.18, 95% CI 0.85–1.65). However, patients that conceived by ART and underwent labor induction had a higher risk of failed induction compared with the control group (adjusted OR 2.53, 95% CI 1.23–5.21). Infants born after ART had a similar birthweight, Apgar score and arterial blood pH compared with spontaneously-conceived ones.LIMITATIONS, REASONS FOR CAUTIONThe database lacked specific information about causes of infertility, smoking habit, family income and details on ART (fresh versus frozen cycle, IVF versus ICSI), limiting, in part, our analysis of the results. However, only autologous IVF/ICSI pregnancies were included in order to prevent bias related to conception by oocyte/embryo donation. In vivo conception ART cases were excluded because they were too few to allow comparison with IVF/ICSI. Nevertheless, the inclusion of only uncomplicated pregnancies provides a highly homogeneous and still representative population sample. Study sample is representative of a well-resourced obstetric facility in a high-income country, limiting to some extent the generalizability of study results.WIDER IMPLICATIONS OF THE FINDINGSPregnancies conceived by autologous ART that proceed uncomplicated until term may require counseling about the risk of placental retention with PPH.STUDY FUNDING/COMPETING INTERESTSThe authors have no conflict of interest and funding to declare.

Nationwide survey of severe postpartum hemorrhage in Japan: an exploratory study using the national database of health insurance claims

Aim: The aim of this study was to investigate epidemiological and clinical aspects of severe postpartum hemorrhage (PPH) in Japan.Methods: We used national health insurance claims from 2011 to 2014 provided by the Ministry of Health, Labour and Welfare. The data included randomly selected claims that covered 10% of all inpatients in October, a so-called sampling dataset (covering 1/120 inpatients per year). We extracted claims for transfused blood, and further narrowed down the claims by names of diseases linked to PPH. As most referral obstetric facilities have adopted the diagnosis procedure combination (DPC)-based payment system while small-scale obstetric facilities have not (non-DPC facilities), the claims were also analyzed separately for DPC and non-DPC facilities. We assessed the incidence and causes of PPH, transfusion volume of red blood cells (RBC) and fresh frozen plasma (FFP), and surgical hemostatic management.Results: The number of PPH cases that required blood transfusion in the sampling dataset was 29, 29, 32, and 36 in 2011, 2012, 2013, and 2014, respectively. The leading cause of PPH was uterine atony followed by placental abruption. Although no specific trends were observed for the volume of transfused RBC (1467 ± 234 ml in 2014), there was a steady increase in the rate of FFP utilization in non-DPC facilities from 37% to 79% over the 4-year sampling period. Intrauterine balloon tamponade emerged in 2014.Conclusion: This nationwide survey indicates that the annual incidence of severe PPH is increasing. Furthermore, FFP has become more prevalent in small-scale obstetric facilities.

Regional Birth Outcomes after the 2011 Great East Japan Earthquake and Tsunami in Miyagi Prefecture.

This study was aimed to analyze post-disaster birth outcomes in coastal and inland regions of Miyagi Prefecture, Japan. Primary data sets were compiled from birth records of obstetric facilities and 12,808 patients were analyzed for baseline birth outcomes by region. Regional risk analysis of the low-birth-weight rate and premature birth rate were conducted using multi-level logistic regression analysis. From overall baseline birth outcomes, a preterm birth rate was 4.6% and low-birth-weight rate was 8.8%. Regional analysis revealed that a preterm birth rate was 3.2% (coastal) and 5.0% (inland), respectively, and the rate of low birth weight was 6.5% in the coastal and 8.5% in the inland region. In the risk analysis of low-birth-weight rate and preterm birth rate, the risk in the coastal region could not be considered any higher than in the inland region (adjusted odds ratio 0.91 [0.73-1.14] and 0.85 [0.46-1.59], respectively). The incidence of preterm birth and low birth weight were not adversely affected by the disaster. Early transfer and intensive medical intervention may have led to those findings. Further survey will be necessary to determine the long-term effects in both mothers and children. Sugawara J , Iwama N , Hoshiai T , Tokunaga H , Nishigori H , Metoki H , Okamura K , Yaegashi N . Regional birth outcomes after the 2011 Great East Japan Earthquake and tsunami in Miyagi Prefecture. Prehosp Disaster Med. 2018;33(2):215-219.

Ghana's community-based primary health care: Why women and children are ‘disadvantaged’ by its implementation

Policy analysis on why women and children in low- and middle-income settings are still disadvantaged by access to appropriate care despite Primary Health Care (PHC) programmes implementation is limited. Drawing on the street-level bureaucracy theory, we explored how and why frontline providers (FLP) actions on their own and in interaction with health system factors shape Ghana's community-based PHC implementation to the disadvantage of women and children accessing and using health services. This was a qualitative study conducted in 4 communities drawn from rural and urban districts of the Upper West region. Data were collected from 8 focus group discussions with community informants, 73 in-depth interviews with clients, 13 in-depth interviews with district health managers and FLP, and observations. Data were recorded, transcribed and coded deductively and inductively for themes with the aid of Nvivo 11 software. Findings showed that apart from FLP frequent lateness to, and absenteeism from work, that affected care seeking for children, their exercise of discretionary power in determining children who deserve care over others had ripple effects: families experienced financial hardships in seeking alternative care for children, and avoided that by managing symptoms with care provided in non-traditional spaces. FLP adverse behaviours were driven by weak implementation structures embedded in the district health systems. Basic obstetric facilities such as labour room, infusion stand, and beds for deliveries, detention and palpation were lacking prompting FLP to cope by conducting deliveries using a patchwork of improvised delivery methods which worked out to encourage unassisted home deliveries. Perceived poor conditions of service weakened FLP commitment to quality maternal and child care delivery. Findings suggest the need for strategies to induce behaviour change in FLP, strengthen district administrative structures, and improve on the supply chain and logistics system to address gaps in CHPS maternal and child care delivery.

Effect of individualised dietary education at medical check-ups on maternal and fetal outcomes in pregnant Japanese women.

An increased prevalence of low maternal weight and insufficient pregnancy weight gain may be responsible for an increase in low birthweight infants in Japan. We aimed to examine the effects of individualised dietary education at medical check-ups on maternal/fetal outcomes in Japanese women. Four hundred and six underweight and normal weight singleton pregnant women, who attended check-ups at an obstetric facility until ≥30 weeks gestation and delivered at 36-41 weeks gestation, were selected for analyses. Weight gain was assessed at each check-up based on the official "Dietary Guidelines for Pregnant and Lactating Women". Individual dietary advice was provided by dieticians to those with insufficient or excess weight gain status around 28 weeks gestation. The medical records from uncomplicated singleton deliveries (36-41 weeks gestation) at the same facility from 2008-2010 were used (n=792) to examine the effect of dietary education on maternal/fetal outcomes. Pre-pregnancy underweight was present in >24% of women in both the intervention and non-intervention groups. Adequate weight gain occurred more frequently in the intervention group (p<0.01). There were no significant differences in mean birthweight or the proportion of low birthweight infants. However, the proportion of extremely small for gestational age infants (birthweight <3rd percentile) was lower in the intervention group (p=0.011). There were no differences in the frequency of caesarean delivery, pregnancy induced hypertension, or infant Apgar scores <7. Dietary education during pregnancy check-ups promotes adequate maternal weight gain and helps prevent extreme fetal growth restraint.

Bypassing health facilities for childbirth in the context of the JSY cash transfer program to promote institutional birth: A cross-sectional study from Madhya Pradesh, India.

Bypassing health facilities for childbirth can be costly both for women and health systems. There have been some reports on this from Sub-Saharan African and from Nepal but none from India. India has implemented the Janani Suraksha Yojana (JSY), a large national conditional cash transfer program which has successfully increased the number of institutional births in India. This paper aims to study the extent of bypassing the nearest health facility offering intrapartum care in three districts of Madhya Pradesh, India, and to identify individual and facility determinants of bypassing in the context of the JSY program. Our results provide information to support the optimal utilization of facilities at different levels of the healthcare system for childbirth. Data was collected from 96 facilities (74 public) and 720 rural mothers who delivered at these facilities were interviewed. Multilevel logistic regression was used to analyze the data. Facility obstetric care functionality was assessed by the number of emergency obstetric care (EmOC) signal functions performed in the last three months. Thirty eighth percent of the mothers bypassed the nearest public facility for their current delivery. Primiparity, higher education, arriving by hired transport and a longer distance from home to the nearest facility increased the odds of bypassing a public facility for childbirth. The variance partition coefficient showed that 37% of the variation in bypassing the nearest public facility can be attributed to difference between facilities. The number of basic emergency obstetric care signal functions (AOR = 0.59, 95% CI 0.37–0.93), and the availability of free transportation at the nearest facility (AOR = 0.11, 95% CI 0.03–0.31) were protective factors against bypassing. The variation between facilities (MOR = 3.85) was more important than an individual’s characteristics to explain bypassing in MP. This multilevel study indicates that in this setting, a focus on increasing the level of emergency obstetric care functionality in public obstetric care facilities will allow more optimal utilization of facilities for childbirth under the JSY program thereby leading to better outcomes for mothers.