Delivery Outcomes Research Articles

National-level assessment of gestational carrier pregnancies in the United States.

To assess national trends, characteristics, and delivery outcomes associated with gestational carriers (GC) pregnancies. This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population was 14,312,619 deliveries between 2017 and 2020. Obstetric characteristics and outcomes associated with GC pregnancies were assessed with inverse probability of treatment weighting propensity score. There were 1965 GCs (13.7 per 100,000) includedfor national estimates. The prevalence rate of GC pregnancies increased by 55.0% over a 4-year period from 11.8 to 18.2 per 100,000 deliveries (P-trend < .001). In the weighted model, GCs were more likely to have a multiple gestation pregnancy (14.7% vs 1.8%, adjusted odds ratio [aOR] 7.83, 95% confidence interval [CI] 6.54-9.38, P < .001), placental abruption (3.5% vs 1.1%, aOR 2.98, 95%CI 2.12-4.19), and low-lying placenta (1.6% vs 0.2%, aOR 5.14, 95%CI 3.10-8.52). Among singleton delivery, odds of late-preterm (10.8% vs 6.4%, aOR 1.79, 95%CI 1.44-2.23) and periviable (1.1% vs 0.4%, aOR 2.54, 95%CI 1.32-4.89) deliveries and postpartum hemorrhage (12.2% vs 4.1%, aOR 3.27, 95%CI 2.67-4.00) were increased for GC compared to non-GCs whereas odds of cesarean delivery (23.6% vs 31.6%, aOR 0.59, 95%CI 0.51-0.69) were decreased. These associations were less robust in multi-fetal gestations. The results of the current nationwide assessment suggest that GC pregnancies are rare but gradually increasing in the United States. This study shows that GC pregnancies have usually favorable pre-pregnancy patient characteristics compared to non-GC pregnancies, with mixed obstetric outcomes including increased odds of preterm delivery, placental abnormalities, and postpartum hemorrhage and decreased odds of cesarean delivery in singleton pregnancies.

A Prospective Evaluation of Health Literacy Levels of Pregnant Women in Antenatal Classes: Impact on Delivery Outcomes in Nulliparous and Multiparous Women.

Backgrounds/Objectives: Modern technology and educational activities, such as antenatal classes (ACs), increase patient informedness in medicine and improve collaboration between physicians and patients. The present study aimed to evaluate and compare the impact of maternal health literacy (HL) on delivery outcomes between nulliparous and multiparous women who attended antenatal classes. Methods: This prospective study recruited 281 pregnant women who regularly attended ACs, but only 188 who gave birth at our academic tertiary hospital were included in the final analysis. Socio-demographic characteristics, peripartum data (cervical dilatation at the time of admission to the hospital, duration of labor, and mode of delivery), and obstetric interventions (cesarean section (C/S) rate and rate of instrumental vaginal birth and episiotomy) were recorded, and the level of HL was assessed using the European Health Literacy Survey Questionnaire (HLS-EU-Q16). HL levels did not significantly affect peripartum and postpartum outcomes. Results: The study results showed that HL levels did not impact labor duration and newborn Apgar scores (p > 0.05). Patient education levels and employment status affected the peripartum duration of labor (p = 0.048 and p = 0.001, respectively). There were no differences in the HL total score and subscale scores (p > 0.05) between nulliparous and multiparous patients, and the rate of primary C/S was similar in both groups. Conclusions: HL levels did not impact delivery (peripartum) outcomes in pregnant women who attended antenatal classes. However, the primary C/S rate was similar between the nulliparous and multiparous groups, which may indicate that antenatal education services can correct the negative impact of low HL levels on the primary C/S rate.

Examining the Effects of Health Work Shortages and Deployment in Integrated Programme in Bihar, India: AnInstitutional Ethnography.

The integration of health programms in low-resource settings is a common approach aimed at providing quality and cost-effective healthcare services. However, programme integration can unintentionally impact service provision and disrupt the overall organisation of service delivery. In this paper, I examine the integrated programme for non-communicable diseases (NCDs) and explore the challenges related to the deployment of health workers. Specifically, I investigate the institutional processes that shape the work of health workers and the working conditions in district hospitals. To explore the social organisation of the implementation of the integrated NCD programme, I employed institutional ethnography as a research method. Data collection involved interviews, participant observation, and document reviews. Data analysis was conducted using social mapping, analytical writing, and textual analysis methods. The findings of the study suggest that due to staff shortages and a lack of doctors, health workers are continuously subjected to deployment and often required to undertake multiple tasks and responsibilities without any incentives or non-monetary benefits. Administrators perceive health workers in integrated programs as additional human resources available for use in district hospitals. However, the removal of health workers from integrated programs can have negative implications for service delivery and patients' health outcomes. Finding of the study suggests that it is recommended that administrators improve the staff recruitment process and promptly address the grievances of health workers to enhance healthcare delivery.

Evaluating the effects of back massage during labour on delivery outcomes: A prospective study on primigravida mothers

The labor and delivery process can be stressful for parturient women, especially for primigravida mothers. Birth companions providing massage and emotional support can help make more pleasant birthing experience. This study aimed to assess the impact of back massage by trained birth companions on reducing analgesic use, pain intensity scores, and labor duration. The study was conducted on primigravida women. During antenatal care visits, companions in the intervention group were trained in massage techniques, while no training was imparted to companions in the control group. Data were collected using a pre-tested questionnaire during antenatal clinic visits and delivery A multivariable logistic regression model was used to assess the impact of massage on delivery outcomes while adjusting for significant confounding variables.The study demonstrated a positive impact of back massaging on labor and delivery outcomes. Mothers in the massaged group were 2.27 times less likely to receive analgesics and 3.71 times more likely to experience a reduction in pain intensity scores of &amp;#62; 2 compared to those receiving usual care. Additionally, the massaged group had a 2.24 times higher likelihood of reducing labor duration to &amp;#60; 12 hours compared to the usual care group. Back massaging by trained birth companions is an effective intervention for reducing the use of analgesics, pain intensity scores, and the length of labor in primigravida women.

A 5-years cross-sectional study of risk-factors feto-maternal outcomes in placenta accreta spectrum at single tertiary care centre in South India

: PAS is an abnormal placental trophoblastic invasion into the myometrium, serosa and surrounding structures causing severe maternal morbidity and mortality due to massive obstetric hemorrhage (MOH). The incidence of PAS is on the rise due to increasing rate of Cesarean Section (CS) worldwide. : This study aimed to assess the risk factors associated with Placenta accreta spectrum (PAS) and to compare the feto-maternal outcomes in elective and emergency delivery in PAS.This is a 5 years single centre cross-sectional study from 1st January 2018 to 31st December 2022. All diagnosed cases of PAS beyond 28 weeks of gestation were included. A total of 38 cases of PAS were studied. Chi-square test and T-test were used to compare the categorical variables with p value 0f &amp;#60;0.05 as statistically significant.The incidence of PAS was 1.85/1000 deliveries. Advanced maternal age, previous CS, placenta previa in current pregnancy were major risk factors. MOH was the commonest complication. The blood loss, increased operative time and need for blood transfusions was mainly dependent on the placental location. Prematurity and low birth weight were the most important perinatal outcomes. Adequate blood and blood products prior to surgery is important as even in expert hands blood loss can be massive. Early referral and specialized regional team to manage PAS at tertiary care are needed. Future studies should emphasize on easy and early detection of PAS.

Should we restrict food intake during labor? A randomized controlled trial.

To evaluate whether consuming food during labor influences its outcomes. This randomized controlled study included healthy, laboring patients at 37-41weeks of gestation. After epidural anesthesia, patients were randomized into groups of eating at will versus drinking clear fluids only. The primary composite outcome included unplanned cesarean delivery, the need for general anesthesia, asphyxia, postpartum fever, and prolonged postpartum admission (more than 5days). Secondary outcomes included the need for oxytocin, length of the second stage of labor, postpartum analgesia requirements, and early maternal and neonatal outcomes. Sample size analysis indicated that 126 patients needed to be randomized to detect a statistically significance difference between the groups. A total of 129 patients were randomized: 58 to the fluids-only group and 71 to the food group. The groups had similar basic characteristics. The composite outcome of complications attributed to eating during labor and delivery was comparable between groups. Labor progression and the need for oxytocin augmentation were similar in both groups. The groups had comparable fetal heart rate tracings, modes of delivery, maternal and neonatal outcomes, and complications. None of the patients in the study experienced aspiration or an indication for general anesthesia. While our data suggest that eating during labor does not adversely affect labor progression or outcomes, we recommend a cautious approach, allowing patients autonomy while considering individual risk factors. The study has been registered in the primary clinical trial registry on 02/12/2023. ISRCTN trial number ISRCTN11794106, registration number 44513. https://www.isrctn.com/ISRCTN11794106 .

Analysis of the relationship between the quality of antenatal care examinations and the incidence of preterm birth and low birth weight

BackgroundAntenatal care (ANC) plays a crucial role in ensuring maternal and child safety and reducing adverse delivery outcomes. This study aimed to analyze the association between the quality of ANC and the occurrence of preterm birth and low birth weight in a sample of the population from 16 regions in 8 provinces in China.MethodsData from all closed cases of pregnant women and newborns reported in the Maternal and Child Health Monitoring System from January 1, 2018, to December 31, 2018, in 16 monitoring regions across 8 provinces in China were collected and included in the analysis, resulting in a total of 49,084 pregnant women and 49,026 newborns.ResultsThe mean number of ANC visits was 6.95 ± 3.45. By percentage, 78.79% of the women received ANC examinations at least five times. The percentage of normative ANC examinations and the percentage of qualified ANC examinations was 30.98% and 8.0% respectively. The gestational age(χ2 = 229.305, p<0.001), birth weight (χ2 = 171.990, p<0.001) and the occurrence of neonatal complications (χ2 = 53.112, p<0.001) were all significantly related to the number of ANC visits to mothers. There was a correlation between gestational age (χ2 = 1021.362, p<0.001;χ2 = 194.931, p<0.001) and birth weight (χ2 = 259.009, p<0.001; χ2 = 70.042, p<0.001) with normative ANC and qualified ANC examinations. As the number of ANC examinations increased, the rates of preterm birth and low birth weight decreased. Pregnant women who did not receive normative ANC examinations had a higher risk of preterm birth and neonatal low birth weight compared to those who did; Adjusted Odds Ratio (95%CI) was 23.33(16.97~32.07)and 1.61(1.37~1.90) respectively. Pregnant women who did not receive qualified ANC examinations had a higher risk of preterm birth and neonatal low birth weight compared to those who did; Adjusted Odds Ratio (95%CI) was 15.05(8.45~26.79)and 1.36 (1.02~1.82) respectively.ConclusionThe percentage of women who received normative ANC examination and qualified ANC examination is still low in China, and the quality of antenatal care significantly affects the occurrence of preterm birth and low birth weight in newborns.

May the indication for a previous cesarean section affect the outcome at trial of labor in women with induction of labor? Aretrospective cohort study.

Cesarean sections are increasing worldwide and are associated with altered risks of complications for both mother and child. Vaginal birth after cesarean section is associated with lower maternal and neonatal morbidity than in repeat cesarean section. Only a few studies have considered the indication for the previous cesarean section to be of importance for the outcome of subsequent labor. The aim of this study was to evaluate whether the indication for a previous cesarean section affects the outcomes at a subsequent delivery in women with induction of labor. This retrospective cohort study of the four largest delivery units in Stockholm during 2012-2015 included 1150 women with one previous cesarean section with induction of labor. women with induced labor and a previous cesarean section, singleton pregnancy, cephalic presentation, gestational age of ≥34 weeks. The women were grouped by indication for the previous cesarean section. mode of delivery (vaginal birth after previous cesarean section or repeat cesarean section). induction to delivery time, postpartum hemorrhage, uterine rupture. Neonatal outcomes: birth weight, Apgar score <7, arterial umbilical cord blood gas pH <7.0. Our study found that the indication of labor dystocia at the previous cesarean section, increased the risk of repeat cesarean section (aOR 5.35; 95% CI: 1.64-17.50) in women with induction of labor. Other risk factors for repeat cesarean section were birth weight >4000 g, maternal BMI ≥30 or if vaginal prostaglandin was used as the method for induction of labor. A previous vaginal delivery and use of oxytocin increased the chance of a vaginal delivery in this group of women. Our study showed that the indication for the previous cesarean section affects the outcome in the subsequent delivery in women with induction of labor. If the indication for the previous cesarean section was labor dystocia, the risk of repeat cesarean section was increased.

Advancements in Clinical Practice: A Comprehensive Review of Emerging Trends in Medical Development

This review article explores the latest advancements in clinical practice, focusing on emerging trends that are transforming healthcare delivery and patient outcomes. Key developments discussed include telemedicine and remote patient monitoring, personalized and precision medicine, artificial intelligence (AI) and machine learning (ML) in diagnostics, robotics and automation in surgery, as well as mobile health applications and wearable devices. Each of these advancements has the potential to enhance the accessibility, accuracy, and efficiency of clinical care. However, these innovations also introduce challenges, such as concerns about data privacy, ethical considerations surrounding AI, and the need for updated regulatory frameworks. The review highlights how these trends contribute to improved patient engagement, cost efficiency, and overall healthcare quality. By examining both the benefits and challenges associated with these developments, this article underscores the importance of innovation in driving the future of clinical practice. Recommendations for future research and policy are also provided to support the continued evolution of healthcare practices.

The interplay of body mass index, gestational weight gain, and birthweight over 3800 g in vaginal breech birth: A retrospective study.

Optimal counseling of women for vaginal breech birth requires consideration of both established and emerging risk factors for adverse perinatal outcomes. Currently, rising prevalences of maternal obesity and impaired glucose tolerance challenge obstetric care. We aimed to investigate the effects of these parameters on the outcome of vaginal breech birth to improve counseling practices. A total of 361 women (without previous vaginal births) attending vaginal birth of a singleton fetus in breech presesntation between 01/2015 and 11/2021 were included in this retrospective single-center study. Data were derived from the hospital data base. We analyzed the effect of the maternal body mass index (BMI) at birth (compared to pre-pregnancy BMI), excessive weight gain, gestational diabetes, and neonatal birthweight on obstetrical and neonatal short-term outcomes (intrapartum cesarean delivery, performance of obstetric maneuvers (Løvset-, Bracht-, Veit-Smellie maneuver and Bickenbach's arm delivery), admission to the neonatal unit, Apgar score after 5 minutes<7, and arterial cord pH-value <7.10). Multivariable logistic regression was used for analysis and adjustment of variables. Overall, 246 women (68.1%) had a successful vaginal birth. Intrapartum cesarean delivery (n = 115/361; 31.9%) was independently associated with maternal BMI at birth (p = 0.0283, aOR = 1.87 (1.19-3.97)) if birthweight was ≥3800 g. The rate of intrapartum cesarean delivery was also higher in women with gestational diabetes (p = 0.0030, aOR = 10.83 (2.41-60.84)). A significantly higher risk of neonatal acidosis (arterial pH-value <7.10) was observed in women with BMI at birth ≥30 kg/m2 (p = 0.0345, aOR = 1.84 (1.04-3.22)) without affecting other outcomes. Pre-pregnancy BMI, gestational weight gain and BMI-gain did not significantly affect the obstetrical and neonatal birth outcomes. When neonatal birthweight is ≥3800 g, maternal BMI at birth (p = 0.0283; aOR = 1.87 (1.19-3.97)) is independently associated with the rate of intrapartum cesarean delivery. However, pre-pregnancy BMI and BMI-gain during pregnancy were not associated with the need for intrapartum cesarean delivery or other adverse outcomes. Consequently, BMI at the time of birth could be more informative than pre-pregnancy BMI and may improve counseling of women attempting vaginal breech birth.

Perinatal optimisation and predictive testing of in utero transfers and their outcome: A regional study.

To review in utero transfers (IUT), their antenatal optimisation strategies including predictive testing and outcomes in a large region in the UK. All IUT requests received by regional transport service in the UK, over a 12-month period, were reviewed gathering information on gestation at referral, antenatal corticosteroid use, tocolysis, magnesium sulphate, predictive test use (and result if applicable) and delivery outcome at 48 h. The reason for transfer was also collated to determine capacity issues. Only 22.9% of women transferred delivered within 48 h of transfer, with only 76% of eligible women receiving antenatal steroids. The overall use of predictive testing was low, in 23.5% of all referrals. Approximately 19.8% of women presenting at 30 weeks gestation or more received predictive testing while only 26.5% of women at risk of extreme preterm delivery had a predictive test, and 40.7% of all IUT requests were for capacity reasons. More predictive testing with accurate approaches to predicting imminent preterm labour and delivery needs to be incorporated into clinical care to reduce the number of inappropriate IUTs. Appropriate antenatal optimisation to improve outcomes should be offered to women undergoing an IUT. Capacity remains problematic leading to a significant number of transfers.

Admission Patterns and Patient Outcomes in Intensive Care Delivery at a Rural Tertiary Hospital in Southern Nigeria: A Five-Year Retrospective Review.

Background Intensive care units (ICUs) play a vital role in managing critically ill patients, yet data on admission patterns and outcomes in rural healthcare settings, particularly in Nigeria, remain limited. Understanding these patterns is essential for improving patient care, especially in resource-limited, rural settings. This study aimed to investigate the admission and outcome patterns of patients admitted to the ICU at Irrua Specialist Teaching Hospital (ISTH), located in a rural part of Edo State, Nigeria. Method This was a retrospective study conducted at ISTH. Data on biodata, primary admission diagnosis, duration of admission, and patient outcomes were collected from the ICU register for all patients admitted to the ICU over a five-year period, from January 1, 2019, to December 31, 2023, and analyzed. Results During the five-year study period, there were 581 ICU admissions, of which 575 (99%) were included in the study after excluding six (1%) due to incomplete data. Among the patients, 297 (51.7%) were female. The young and middle-aged group (20-59 years) accounted for 60% (365) of admissions. Surgical cases comprised the majority of admissions at 57.9% (333), followed by medical cases at 25.9% (149) and obstetric/gynecologic casesat 16.2% (93). The most common sources of admission were general surgery (211, 36.7%), obstetrics (75, 13%), and neurosurgery (43, 7.5%), with the most frequent diagnoses being generalized peritonitis secondary to perforated viscus (102, 17.7%), bowel obstruction (36, 6.3%), preeclampsia/eclampsia (28,4.9%), traumatic brain injury (TBI) (27, 4.7%), and stroke (26, 4.5%). The overall mortality rate was 49.2%and was significantly associated with age, duration of admission, type of case, and subspecialty (p < 0.05). Conclusion The study highlights admission and outcome patterns that reflect the challenges faced in rural ICU settings. The high mortality rate highlights the need for improved critical care resources and targetedinterventions to improve outcomes of critically ill patients in similar resource-limited settings.

Case of delayed diagnosis of combined urogenita and pulmonary tuberculosis in a patient with abnormal uterine bleeding

According to the World Health Organization tuberculosis remains a global health issue for both adult and pediatric populations worldwide. Among women the peak incidence occurs during the active reproductive age, with pregnant women being 1.5–2 times more likely to be affected and experience more severe symptoms than non-pregnant women. In the Altai Region, the epidemiological situation of tuberculosis is characterized by instability, with the incidence rate among women reaching30.5 per 100 000 of the corresponding population in 2022. Delayed diagnosis and treatment can lead to serious complications, including fatal outcomes for both mother and fetus. This article describes a clinical observation of a case of urogenital and pulmonary tuberculosis diagnosed three months after premature abdominal delivery. The course of pregnancy was complicated by acute pleuritis at 13–14 weeks, however, negative results of bacteriological culture of pleural fluid led to the absence of specific tuberculosis treatment and the development of chronic subcompensated placental dysfunction. Three months after delivery, a 34-year-old patient was admitted to the gynecological department of the emergency hospital with abnormal uterine bleeding. The diagnosis was confirmed by histopathology of an endometrial sample revealing tuberculous granulomas without caseous necrosis with epithelioid giant cells of Pirogov – Langhans. Subsequently, generalized tuberculosis was diagnosed in the preterm infant. The negative impact of undiagnosed combined urogenital and pulmonary tuberculosis on the course and outcome of pregnancy is demonstrated, including the development of anemia, placental dysfunction, preterm delivery, puerperal complications, and adverse perinatal outcomes.

Stimuli-Responsive Nano/Biomaterials for Smart Drug Delivery in Cardiovascular Diseases: Promises, Challenges and Outlooks.

Cardiovascular Diseases (CVDs) are responsible for the highest number of deaths and disabilities globally. Although numerous therapeutic options exist for treating CVDs, most traditional strategies have proven ineffective in halting or significantly slowing disease progression, often leading to unfavorable side effects. Using nanocarriers represents an innovative strategy for treating CVD, enabling the personalized delivery of medications to precise locations within the cardiovascular system. Despite significant advancements in pharmacological treatments, challenges persist in effectively administering drugs to the CV system. Employing nanocarriers represents an innovative strategy for treating CVD, enabling the tailored administration of medications to precise locations within the cardiovascular system. Various studies have determined the future outlook of nanomedicines for clinical applications as nanocarrier design continues to improve, leading to enhanced drug delivery and treatment outcomes. The article focuses on the delivery systems of drugs that are effective strategies for treating cardiovascular diseases. This manuscript also seeks to explore new possibilities for how the emerging concept of nanotherapeutics could revolutionize our traditional diagnostic and treatment methods in the coming years.

Optimizing last-mile delivery of essential medicines in Nigeria: Insights from Niger State’s health-care supply chain

Last-mile delivery of health commodities is a critical component of efficient supply chains, and third-party logistics (3PL) providers are pivotal in ensuring cost-effective and reliable product distribution. This study explores the implementation of last-mile delivery outsourcing by government-operated warehouses and drug management agencies (DMAs). This research focuses on the relationship between 3PL utilization and key performance metrics, such as cost reduction, timely delivery, and end-user satisfaction. This study combines a literature review, surveys, and interviews conducted with employees of the DMAs in Minna, Niger State, to establish significant correlations. The findings show that using 3PLs significantly reduced operational costs, improved the frequency of timely deliveries, and enhanced end-user satisfaction. These findings underscore the need for continued engagement with 3PL providers to optimize supply chain performance and improve service delivery outcomes. Managers are recommended to maintain and expand such collaborations to sustain these benefits.

Long-term maternal outcomes 5 years after cesarean section in Sierra Leone: A prospective cohort study.

Cesarean section (CS) is a life-saving procedure when performed for the right indication but carries substantial risks, specifically during subsequent pregnancies. The aim of this study was to evaluate obstetric outcomes for women 5 years after a CS performed by medical doctors and associate clinicians. This was a prospective multi-center observational study of women who had a CS at any of nine hospitals in Sierra Leone. Women and their offspring were followed up with three home visits for 5 years after surgery. Outcomes of interest included long-term complications, mode and place of delivery, and maternal and pediatric outcomes of subsequent pregnancies. Of the 1274 women included in the study, 140 (11.0%) were lost to follow-up. Within 5 years after the index CS, 27.0% of the women became pregnant and 2.5% had a second pregnancy. Women with perinatal death at the index CS had 5.25 higher odds of becoming pregnant within 1 year. Of the 259 women who delivered, 31 (12.0%) had a planned CS and 228 (88.0%) attempted a trial of labor after CS, resulting in either a successful vaginal birth (n = 138; 60.5%) or an emergency CS (n = 90; 39.5%). Peripartum and long-term complications did not significantly differ between those that were operated on by medical doctors and associate clinicians. Within 5 years after CS, one in four women became pregnant again and more than half had a vaginal delivery. Significant differences in place and mode of birth between wealth quintiles illustrate inequities.

Endometriosis and risk factors in pregnancy, labor and delivery: a case-control study.

It is a common thought that endometriosis and its related pain symptoms could improve during pregnancy. However, endometriosis was shown to affect the regular development of pregnancy and delivery outcomes. Several adverse events may occur in the peri-implantation period, and may perpetuate throughout the pregnancy of patients diagnosed with the disease. We analyzed pregnancy, delivery and neonatal outcomes in two groups of patients (case and control group), a total of 91 women with endometriosis were 1:3 matched to 273 controls by age. Diagnosis of endometriosis was histologically confirmed and a database with general medical and gynecological history, pregnancy course, delivery mode and newborn conditions was analyzed. Patients with endometriosis presented higher rates of gestational hypertension (4.4% vs. 0.8%, P=0.02), pre-eclampsia (2.2% vs. 0, P=0.014) and placenta previa (3.3% vs. 0, P=0.003). Caesarean delivery (29.6% vs. 11.3%, P value <0.01) and postpartum hemorrhage (26.5% vs. 11.9%, P=0.04) were more common among patients diagnosed with endometriosis. Multivariate logistic regression showed that cesarean delivery was associated with endometriosis, hypertension and prior cesarean delivery. Postpartum hemorrhage is significantly higher in women treated for endometriosis (26.5% vs. 11.9%, P=0.037). Endometriosis is related to a higher risk of preeclampsia, placenta previa and postpartum bleeding but it does not increase the risk of cesarean delivery during labor. Obstetricians should consider such associations when managing pregnant patients with a history of endometriosis.

The art of effective communication between family physicians and their adolescent patients: Challenges and solutions.

Healthcare delivery and excellent health outcomes for teenagers depend on the establishment of effective communication between family physicians and adolescent patients. However, communicating with adolescents can be challenging due to their stage of development and unique needs. By implementing effective communication strategies and fostering a positive environment, family doctors can build trust, enhance patient participation and ultimately improve health outcomes for their adolescent patients. This article explores the value of excellent communication in the healthcare of teenagers, identifies potential barriers that family doctors might encounter and provides solutions to overcome these challenges. Adolescence is a critical developmental stage marked by physical, emotional and social changes, making effective communication particularly challenging. During this phase, adolescents might face various health concerns, including mental health issues, substance use, sexual health and chronic diseases. This emphasises the importance of tailoring communication strategies to connect with the adolescent mind. Active listening, using age-appropriate language, incorporating technology, empathy, promoting autonomy and shared decision making are tools to open communication bridges between healthcare providers andtheir adolescent patients.

Identifying the active ingredients in payment for performance programmes using system dynamics modelling

Payment for performance (P4P) is not a uniform intervention, with programme effect dependent on several interconnected factors. In this study, a system dynamics model was developed to explore the pathways to improved outcomes and how changes in the design, implementation and context of a P4P programme affected maternal and child health (MCH) service delivery outcomes in Tanzania. A previously developed causal loop diagram of the programme effects was used to inform model development, with further data sources (including an impact evaluation of programme, health surveys, stakeholder feedback and relevant literature) used to build the model. A number of pathways were identified to improved services under P4P, with increased availability of drugs underpinning the content of care outcome (intermittent preventative treatment during ANC), which together with increased supervision, enhanced health worker motivation. This in turn increased perceived quality of care at the facility which improved the coverage of services outcome (facility-based deliveries), and with increased outreach, increased awareness of services also boosted demand. Minor delays in payment reduced provider purchasing power for medicines, with severe delays driving erosion of provider trust and motivation for programme participation. Allocating a larger share of funds for facility operations can enhance performance effects, particularly for those services that rely on efficient drug administration. Contextual factors including limited baseline provision of essential medications, lower community awareness of facility services and dispersed/distant populations reduced programme effect. This paper demonstrates the feasibility and the potential of such models to inform the design of effective health system interventions.

Lower uterine segment thickness to predict uterine rupture: a secondary analysis of PRISMA cluster randomized trial

BackgroundThird-trimester lower uterine segment thickness (LUST) is associated with uterine rupture during trial of labor after cesarean (TOLAC) but threshold values vary according to the approach used (lower values with vaginal ultrasound, higher values with abdominal ultrasound). ObjectiveTo estimate the optimal LUST cut-off value combining vaginal and abdominal ultrasound to predict uterine rupture during TOLAC. Study DesignWe performed a secondary analysis of PRISMA cluster randomized trial including women with a single previous cesarean who underwent ultrasound LUST measurement at 34-38 weeks using the thinnest measurement obtained by combining transvaginal and transabdominal measurements. Participants in the intervention group were informed about the risk of uterine rupture according to LUST reported in 3 categories [≥2.5 mm: low risk - TOLAC is safe; 2.0-2.4 mm: intermediate-risk - TOLAC is safe under specific conditions (e.g. Grobman estimate of vaginal delivery of at or above 70 percent and/or having a history of vaginal delivery; estimated fetal weight below 4000 grams; inter-delivery interval ≥18 months); <2.0 mm: high-risk for uterine rupture]. Delivery outcomes including uterine rupture were compared using non-parametric analyses and receiver operating characteristics (ROC) curves. ResultsAmong 3460 participants, 2809 (81%); 385 (11%); and 266 (8%) were identified at low-; intermediate-; and high-risk for uterine rupture, respectively. As expected, low-risk participants were more likely to undergo TOLAC (49% vs 46% vs 13%; p<0.001) and more likely to undergo labor induction (16% vs 12% vs 3%, respectively; p<0.001) than intermediate-risk and high-risk participants. Four (0.3%) cases of uterine rupture during TOLAC occurred among 1382 low-risk participants but none among the intermediate-risk (0/178) and high-risk (0/35) participants (p=0.73). Among low-risk participants, uterine rupture was associated with LUST combining vaginal and abdominal ultrasound (area under the ROC curve : 0.93; 95% confidence interval: 0.86 – 0.99; p<0.001) with all cases occuring among women with LUST between 2.5 and 3.0 mm (4/371 or 1.1%) compared to none (0/1011) among those with LUST ≥3.0 mm (p<0.01). ConclusionsThird-trimester LUST measurement influences the rates of TOLAC and uterine rupture. TOLAC appears to be associated with a low risk of uterine rupture with a LUST between 2.0 and 2.4 mm under specific conditions. However, these conditions should perhaps be extended to patients with a LUST of less than 3.0 mm, as we found an increase in uterine ruptures in this sub-group (between 2.5 and 3.0 mm) who had no special conditions to comply with. LUST ≥3.0 mm combining vaginal and abdominal ultrasound was associated with a very low risk for uterine rupture. A large-scale study using these new parameters would have the potential to demonstrate a reduction in uterine ruptures during TOLAC.