Referral Maternity Research Articles

Factors Influencing Contraception Usage: A Cross-Sectional Study among Mothers Receiving Abortion Services in Orotta Maternity Hospital, Eritrea

Background: Contraception usage helps in preventing unintended pregnancies and unsafe abortions as well as avoiding sexually transmitted disease including HIV. This study was aimed to determine the contraception prevalence and its influencing factors among mothers receiving abortion services in Orotta Maternity Hospital. Methods: Using a cross-sectional study, 250 mothers receiving abortion services in Orotta national referral maternity and teaching hospital were surveyed over a period of three months, December 2018 through February, 2019. Patient demographic and obstetric data were collected using a pretested questionnaire. Bivariate and multivariate logistic regression models were utilized to identify factors influencing contraception usage using SPSS (Version 22.0). Results: The prevalence of contraception usage was 26.4 %. Young mothers aged less than 31 years (P value: 0.029), and those who were primigravida (P value: 0.004) were more likely to use contraception (p value 0.03). Conclusion: Contraception usage rate was low in the current study. Better family planning systems and more counselling opportunities are needed to scale up the usage of contraception.

Can pre-eclampsia explain higher cesarean rates in the different groups of Robson's classification?

To evaluate the impact of pre-eclampsia on cesarean delivery by using the Robson classification. A retrospective cross-sectional study including all women who delivered in a referral maternity hospital in southeast Brazil from January 2017 to February 2018. Women were classified into 1 of 10 Robson groups and then further subdivided into pre-eclampsia (PE) and non-PE (NPE) groups. Frequency of cesarean was determined for each group and compared by using χ2 and prevalence ratio. Overall, 3102 women were included, of whom 1578 (50.9%) delivered by cesarean. Classification in Robson group 5 was the most frequent among all women (n=727, 23.4%). In the PE group (n=258, 8.3%), group 10 was the most frequent classification (n=120, 46.5%); in NPE, Robson group 5 was the most frequency (n=682, 24.0%). Pre-eclampsia was associated with a higher occurrence of cesarean (77.5% vs 48.4%; prevalence ratio, 2.29; 95% confidence interval, 1.82-2.82), owing to higher rates in Robson groups 1, 5, and 10. Pre-eclampsia was associated with a higher occurrence of cesarean delivery in some Robson groups. Robson classification may be used to evaluate the impact of specific conditions at a facility level to help plan future interventions to optimize the use of cesarean.

Factors associated with neonatal near miss and death in public referral maternity hospitals

Abstract Objectives: to evaluate factors associated with neonatal near miss and death in reference hospitals. Methods: this case-control study included 364 cases and 728 controls among 4,929 births. Cases were identified by Apgar < 7 at 5 minutes, weight < 1500 g, gestational age <32 weeks, mechanical ventilation or congenital malformation. After follow-up, outcomes were reclassified into: true controls, near miss and neonatal death. Hierarchically, variables with a p-value < 0.20 were included in the multiple logistic regression. Results: the neonatal near miss rate was 54.1 per 1,000 live births, and the near-miss-to-death ratio was 2.75. Between the control and near miss groups, the predictor variables were neonatal intensive care admission [OR = 35.6 (16.7 - 75.9)] and central venous access [OR= 74.8 (29.4 - 190.4)]. Between the control and death groups, neonatal intensive care admission [OR = 100.4 (18.8 - 537.0)] and central venous access [OR = 12.7 (3.7 - 43.2)] were significant. Between the near miss and death groups, only Apgar < 7 at 5 minutes [OR = 4.1 (1.6 - 10.6)] and vasoactive drug use [OR = 42.2 (17.1 - 104.5)] were significant. Conclusion: factors associated with a greater chance of near miss and/or neonatal death were: Apgar score <7 at 5 minutes, neonatal intensive care confinement, having central venous access, and use of vasoactive drugs.

Clinical and epidemiological factors associated with spontaneous preterm birth: a multicentre cohort of low risk nulliparous women

The objective of this study was to determine incidence and risk factors associated with spontaneous preterm birth (sPTB). It was a prospective multicentre cohort study performed in five Brazilian referral maternity hospitals and enrolling nulliparous women at 19–21 weeks. Comprehensive maternal data collected during three study visits were addressed as potentially associated factors for sPTB. Bivariate and multivariate analysis estimated risk ratios. The main outcomes measures were birth before 37 weeks due to spontaneous preterm labour or premature rupture of membranes (sPTB). The comparison group was comprised of women with term births (≥37weeks). Outcome data was available for 1,165 women, 6.7% of whom had sPTB, 16% had consumed alcohol and 5% had used other illicit drugs during the first half of pregnancy. Current drinking at 19–21 weeks (RR 3.96 95% CI [1.04–15.05]) and a short cervix from 18–24 weeks (RR 4.52 95% CI [1.08–19.01]) correlated with sPTB on bivariate analysis. Increased incidence of sPTB occurred in underweight women gaining weight below quartile 1 (14.8%), obese women gaining weight above quartile 3 (14.3%), women with a short cervix (<25 mm) at 18–24 weeks (31.2%) and those with a short cervix and vaginal bleeding in the first half of pregnancy (40%). Cervical length (RRadj 4.52 95% CI [1.08–19.01]) was independently associated with sPTB. In conclusion, the incidence of sPTB increased in some maternal phenotypes, representing potential groups of interest, the focus of preventive strategies. Similarly, nulliparous women with a short cervix in the second trimester require further exploration.

Perfil epidemiológico de gestantes/puérperas soropositivas para o HIV em uma maternidade de referência em Belém-PA

Objetivo: Descrever o perfil epidemiológico de gestantes/puérperas soropositivas para o HIV atendidas em uma maternidade pública de referência em gestação de alto risco- no município de Belém-Pará. Métodos: Trata-se de um estudo transversal, observacional de caráter descritivo com abordagem quantitativa. Realizado em uma maternidade de referência em Belém-PA. Resultados: Faixa etária predominante foi de 21 a 25 anos (48,0%), 80% se declarou de cor parda, metade é da região metropolitana de Belém e outra do interior do estado, 70% exercem atividades do lar, 48% tinham o ensino fundamental incompleto, 70% vivem em união estável, e 72% possuem renda familiar de 1 a 3 salários mínimos. Quanto aos hábitos de vida: 12% fumaram, 18 % consumiram bebidas alcóolicas e apenas 4 % usaram drogas ilícitas/injetável nesta gestação. Conclusão: Conclui-se que o perfil das gestantes puérperas soropositivas se assemelha com os descritos na literatura, por vezes existindo peculiaridades da nossa região. Necessidade de ampliação do diagnóstico de infecção para todas as mulheres jovens, de acordo com as políticas de saúde da mulher.

Influence in the reproductive planning and the women's satisfaction with the discovery of being pregnant in the quality of prenatal care in Brazil

Abstract Objectives: to analyze the influence on reproductive planning and the women's satisfaction with the discovery of being pregnant in prenatal care characteristics. Methods: a cross-sectional and quantitative study was carried out between March and July 2018 at a low-risk maternity hospital in the Brazilian Northeast region. A total of 652 puerperal women were evaluated in an interview and by their prenatal care card. The Chi-square test and the Odds Ratio were used for statistical analysis. Results: the pregnancy planning was reported by 42% (n=274), and the women's satisfaction of being pregnant was 64.1% (n=418) of the interviewees. Reproductive planning was associated with early initiation of prenatal care (OR=2.48, CI95%=1.61-3.82) and the women received information about the referral maternity for childbirth (OR=1.44, CI95%=1.05-1.99). The women's satisfaction with their pregnancy was also associated with early initiation of prenatal care (OR=2.18; CI95%=1.47-3.25). It should be noted that the performance of six or more prenatal care consultations was less frequent among pregnant women who had not planned their pregnancy (OR=0.43, CI95%=0.27-0.66) and they felt unsatisfied with the discovery of being pregnant (OR=0.56; CI95%=0.37-0.84). Conclusions: Pregnancy planning and women's satisfaction with the discovery of being pregnant favors the performance of prenatal care with better indicators.

Skin Color and Severe Maternal Outcomes: Evidence from the Brazilian Network for Surveillance of Severe Maternal Morbidity.

Background Taking into account the probable role that race/skin color may have for determining outcomes in maternal health, the objective of this study was to assess whether maternal race/skin color is a predictor of severe maternal morbidity. Methods This is a secondary analysis of the Brazilian Network for Surveillance of Severe Maternal Morbidity, a national multicenter cross-sectional study of 27 Brazilian referral maternity hospitals. A prospective surveillance was performed to identify cases of maternal death (MD), maternal near miss (MNM) events, and potentially life-threatening conditions (PLTC), according to standard WHO definition and criteria. Among 9,555 women with severe maternal morbidity, data on race/skin color was available for 7,139 women, who were further divided into two groups: 4,108 nonwhite women (2,253 black and 1,855 from other races/skin color) and 3,031 white women. Indicators of severe maternal morbidity according to WHO definition are shown by skin color group. Adjusted Prevalence Ratios (PRadj - 95%CI) for Severe Maternal Outcome (SMO=MNM+MD) were estimated according to sociodemographic/obstetric characteristics, pregnancy outcomes, and perinatal results considering race. Results Among 7,139 women with severe maternal morbidity evaluated, 90.5% were classified as PLTC, 8.5% as MNM, and 1.6% as MD. There was a significantly higher prevalence of MNM and MD among white women. MNMR (maternal near miss ratio) was 9.37 per thousand live births (LB). SMOR (severe maternal outcome ratio) was 11.08 per 1000 LB, and MMR (maternal mortality ratio) was 170.4 per 100,000 LB. Maternal mortality to maternal near miss ratio was 1 to 5.2, irrespective of maternal skin color. Hypertension, the main cause of maternal complications, affected mostly nonwhite women. Hemorrhage, the second more common cause of maternal complication, predominated among white women. Nonwhite skin color was associated with a reduced risk of SMO in multivariate analysis. Conclusion Nonwhite skin color was associated with a lower risk for severe maternal outcomes. This result could be due to confounding factors linked to a high rate of Brazilian miscegenation.

Exploring the effect of the \u2018Growing Together\u2019 parenting education kit on early parenting - study protocol for a cluster randomised controlled trial

BackgroundSignificant gaps exist in education for prospective and new parents, especially for some of the most vulnerable families. Prospective parents would like more information during pregnancy to prepare them for parenting, and need access to trusted and quality information.The Royal Women’s Hospital (the Women’s) in Melbourne, Australia, a large tertiary referral maternity hospital, developed a parenting education kit known as ‘Growing Together’. The kit, designed to guide prospective and new parents from conception until 1 year after birth, includes three components: an A4 sized book, a specifically designed ‘App’ and a children’s story book. We aim to evaluate the impact of the kit on a range of outcomes.MethodsA two-arm cluster randomised controlled trial will be used. Antenatal clinic days will be randomised to either the intervention or standard care arms. Women in the intervention arm receive the kit at their antenatal booking visit. Women in the standard care arm receive the standard information resources at the Women’s. Analyses will be by intention to treat. Inclusion criteria: primiparous women with adequate English-speaking ability and ≤ 30 weeks’ gestation at first pregnancy booking appointment.The primary outcome of the study is the ‘experience of motherhood questionnaire’ (EMQ), a 20 item validated self-report measure, ranging from 0 to 80, with lower scores indicating better maternal health and wellbeing. To detect a 10% difference in new mothers scoring ≤40 between women who have received the kit (60%) and those who have not (50%), would require 408 per group (total of 816 women) with 95% confidence and 80% power. Allowing for loss to follow up, we aim to recruit 1000 mothers. Secondary outcomes include parents’ views and experiences of their care and of the kit during pregnancy and after the birth, parental attachment, knowledge, confidence, wellbeing and health-seeking behaviour; and emotional, developmental and physical health of the infant. Survey data will be collected from mothers at 2, 6 and 12 months postpartum and partners at 6 months.DiscussionThis study will provide much needed high-level evidence on the impact of a comprehensive education resource for new parents.Trial registrationANZCTRN12615000270516 - Retrospectively registered (23/03/2015); trial started on 16 March 2015.

Use of short text message reminders to improve attendance of postnatal care at a referral maternity hospital, Kenya, 2016�A randomised controlled trial

INTRODUCTION: Globally about 830 women die daily due to complications of pregnancy and child birth out of which 550 occur in Sub-Saharan Africa, with about 8,000 maternal deaths occurring annually in Kenya. 66% of maternal deaths occur within the first week and 85% of maternal deaths occur within two weeks post-delivery. Attendance of postnatal services during this time could significantly reduce morbidity and mortality. We determined effectiveness of short text message (SMS) in reducing failure-to-attend rates (FTA) of postnatal clinic at the largest maternity hospital in Nairobi, Kenya. METHODS: We conducted a hospital-based randomised controlled trial. Women who delivered between March and May 2016 at Pumwani Maternity Hospital were recruited, enrolled and randomised into SMS (intervention) or no SMS (control) arms. Women were masked to which arm they belonged during randomisation but were unmasked during the appointments as the intervention had been sent. The investigators were not masked. Reminders were sent three days prior to and on the morning of the appointment. Relative Risk (RR) at 95% Confidence Interval were calculated to estimate the effectiveness of intervention at two and six-weeks. RESULTS: We enrolled 754 women, with 377 randomly assigned into each arm. There were no differences in socio-demographic characteristics between the study arms at baseline. After two-weeks, women in the intervention arm had an 80% reduction in FTA risk (RR=0.2, 95% CI 0.1–0.3). After six weeks, women in the intervention arm had a 60% reduction in FTA risk (RR=0.4, 95% CI 0.2–0.6). Among participants, 80 (42.1%) women at two-weeks and 30 (41.7%) women at six-weeks cited forgetting appointment as the most common reason for failing to attend postnatal clinic. CONCLUSION: SMS reminders were effective in reducing failure-to-attend clinic appointments. We recommend the use of SMS reminder strategy for postnatal care.

Maternal characteristics and type of prenatal care associated with peregrination before childbirth

ABSTRACTOBJECTIVE To analyze the maternal characteristics and type of prenatal care associated with peregrination before childbirth among pregnant women in a northeastern Brazilian state.METHODS Quantitative and transversal study, with descriptive and analytical approaches, part of the Nascer em Sergipe research held between June 2015 and April 2016. A total of 768 puerperal women proportionally distributed across all maternities of the state (n = 11) were evaluated. Data were collected in interviews and from prenatal records. The associations between antepartum peregrination and the exposure variables were described in absolute and relative frequencies, crude and adjusted odds ratios and their respective confidence intervals.RESULTS Antepartum peregrination was reported by 29.4% (n = 226) of the interviewees, most of whom sought care in a single service before the current one (87.6%; n = 198). It should be noted that antepartum peregrination was less frequent among women aged ≥ 20 years old (OR = 0.50; 95%CI 0.34–0.71), with high education level (OR = 0.42; 95%CI 0.31–0.59) and a paid job (adjusted OR = 0.59; 95%CI 0.41–0.82), who had been instructed during prenatal care about the referral maternity for childbirth (adjusted OR = 0.88; 95%CI 0.42–0.92), and who used the private service to receive prenatal (adjusted OR = 0.44; 95%CI 0.18–0.86) or childbirth (adjusted OR = 0.96; 95%CI 0.66–0.98) care. No statistical evidence of associations between gestational characteristics and the occurrence of peregrination was observed.CONCLUSIONS Antepartum peregrination suffers interference from the mother’s socioeconomic characteristics, the type of prenatal care received and the source of funding for childbirth.

The Problematics of Transferred Parturient Women in Guinean Urban Areas: The Case of the Donka Maternity Ward at the University Hospital Centre (Chu) Conakry

Objectives: To describe the socio-demographic aspects of transferred parturient women; To identify the means of transport used by the evacuated parturient women to the Donka maternity ward at the University Hospital of Conakry; To describe the difficulties met; And to assess maternal and fetal prognosis. Methodology: It consisted of a prospective study over a period of 6 months from 01/02 to 31/07/2018. All patients transferred to the maternity ward of the Donka National Hospital of Conakry University Hospital. Results: The frequency of obstetric transfers was 13.79%. The epidemiological profile was that of a parturient woman of an average age of 25.7 years, married, and housewife, unschooled, who was on her first pregnancy and from the city of Conakry. The average distance covered was 16 km with extremes of 3 and 50 km. The transfer to the referral maternity clinic was not medicalized in 94% of cases. The venous route was not taken in 96% of cases. The parturient was not escorted by a health worker in 98% of cases. Bleeding was the most frequent reason for evacuation, followed by acute fetal sufferings. The average number of prenatal consultation was 2 with extremes of 0 and 9. The average length of stay was 3.6 days with extremes of 1 and 28 days. The majority of transferred women had a full-term pregnancy. The Cesarean section was 79.4%. The Retro placental hematoma was the most common complication found and was 29.4%. The counter-reference was not made in 97.79%. We recorded 8 maternal deaths, for a lethality rate of 1.77%. Possible interventions to reduce the dramatic situation of obstetric evacuations require first of all the decentralization of health care structures capable of performing a cesarean section. This approach should aim to create medical centers with a surgical antenna in all municipalities. These decentralized units would reduce the delay in case management and thus, limit the number of complications.

Examining the infectious aetiology and diagnostic criteria of maternal pyrexia in labour to improve antibiotic stewardship

ObjectivesTo determine the infectious aetiology of peripartum maternal pyrexia and to assess the diagnostic accuracy of obstetric systemic inflammatory response syndrome criteria and cardiotocography as predictors of peripartum infection, in order to guide appropriate antibiotic management of mother and neonate.Study DesignThis study was carried out in a tertiary referral maternity hospital in Dublin, Ireland. A prospective cohort analysis was performed of 175 mother-newborn pairs with maternal pyrexia (≥38 °C) that developed after labour onset or within four hours postnatal. Infection was confirmed microbiologically in the case of sterile site infection, urinary tract infection (UTI) or growth of a significant perinatal pathogen from a placental swab. Infection was confirmed histologically by gross and microscopic examination of placentas in cases where there was growth of potentially pathogenic micro-organisms at a non-sterile site. Systemic inflammatory response syndrome criteria and cardiotocography in patients with confirmed infection versus those without evidence of infection were compared using independent samples t-test for continuous data and pearson chi-square test for nominal data. Diagnostic accuracy of obstetric systemic inflammatory response syndrome criteria (elevated maternal heart rate, elevated respiratory rate, decreased systolic blood pressure and elevated white cell count) for the identification of infection among women with peripartum pyrexia was determined using receiver operating characteristic curves.ResultsThe infection rate was 17.1% (30/175). The rate was 22% (22/100) for pyrexia that occurred during labour and 10.7% (8/75) if it occurred within four hours after delivery. Obstetric systemic inflammatory response syndrome criteria and cardiotocography were not predictive of infection in women with peripartum pyrexia. No significant differences were observed in mean temperature, heart rate, respiratory rate, systolic blood pressure or white cell count between those with infections and those with no evidence of infection.ConclusionsPeripartum pyrexia is predominantly of non-infectious origin. Improved diagnostic criteria are needed to identify infection for this indication. Early discontinuation of antibiotic treatment is appropriate in the majority of patients who develop term peripartum pyrexia after onset of labour.

Relação entre ocorrência de endometriose e sofrimento psiquíco

Objetivo: Compreender a relação existente entre a ocorrência de endometriose e o sofrimento psíquico presente nas mulheres. Métodos: Estudo qualitativo com 11 mulheres com endometrioseno seu primeiro atendimento no ambulatório de endometriose da Maternidade Escola Assis Chateubriand (MEAC), de setembro de 2016 a janeiro de 2017. A coleta de dados ocorreu pelas entrevistas narrativas. Após leitura e transcrição minuciosa das entrevistas, extraiu-se uma categoria para análise. Resultados: A busca incessante pelos serviços de saúde no tratamento das dores incapacitantes são condições que contribuem para a alteração do humor da mulher. A demora no diagnóstico e intervenção leva à mulher a frustração e, frequentemente, a reação estressante. Mesmo após o diagnóstico e a instituição do tratamento, os fatores psicológicos que fazem parte da síndrome dolorosa, como a mudança no humor e a ansiedade, contribuem diretamente para melhorar ou piorar o estado de saúde da mulher. E ainda necessitam de uma abordagem holística para visibilidade dos sintomas, precisando de um suporte emocional para lidar com a doença. Conclusão: A qualidade de vida, valor atribuído à duração da vida quando esta é transformada pela percepção de limitações físicas, psicológicas, funções sociais e oportunidades motivadas pela doença, tratamento e outros agravos, deve ser um aspecto observado no tratamento de pacientes com endometriose, sobretudo quando se consideram a influência dos aspectos psíquicos no tratamento da doença biológica. Em concordância com este sentido sobre a percepção da saúde, as funções sociais, psicológicas e físicas das mulheres com endometriose necessitam ser repensadas e reconfiguradas.

Predictive validity of the Postpartum Depression Predictors Inventory-Revised (PDPI-R): A longitudinal study with Portuguese women

ObjectiveThis study examined the predictive validity of the prenatal and postnatal versions of the Postpartum Depression Predictors Inventory-Revised (PDPI-R) in European Portuguese women, considering two gold standards to determine postpartum depression (PPD). DesignProspective longitudinal study conducted between November 2015 and September 2017. SettingOne public referral maternity hospital in the central region of Portugal. ParticipantsA total of 140 Portuguese women participated in the study. MeasurementsParticipants completed the PDPI-R during the second trimester of pregnancy (T1) and at 6 weeks postpartum (T2). At T2, participants also answered the Edinburgh Postnatal Depression Scale (EPDS). During the fourth month postpartum (T3), women were interviewed with the Structured Clinical Interview for DSM-IV Disorders, and between 6 and 9 months postpartum (T4), they completed the EPDS. FindingsRates of clinically significant depressive symptoms (EPDS ≥ 10) were 16.4% (23/140) at T2 and 23.2% (23/99) at T4. Six (4.3%) women met the criteria for a clinical diagnosis of PPD (major depressive episode) at T3. Overall, the postnatal version of the PDPI-R performed better than did the prenatal version (average area under the curve = 82% vs. 71%), but both versions accurately predicted women who developed a clinical diagnosis of PPD, at a cut-off score of 4.5 for the prenatal version (sensitivity = 83.3%; specificity = 85.8%) and 9.5 for the postnatal version (sensitivity = 83.3%; specificity = 94.8%). Key conclusions and implications for practiceDespite the low prevalence of PPD (albeit consistent with prior estimates of major depression at three months postpartum), this clinical condition has very serious consequences for the mother, the baby and the whole family when present. The PDPI-R is a valid screening tool to estimate the psychosocial risk for developing PPD among Portuguese women and can be used in research (e.g., for cross-cultural comparisons) and clinical practice. The recommended cut-off scores could assist health professionals (namely, midwives) in identifying the women who would benefit from appropriate referrals and/or closer monitoring to prevent them from developing PPD.

\u201cIn the hospital, there will be nobody to pamper me\u201d: a qualitative assessment on barriers to facility-based delivery in post-Ebola Sierra Leone

BackgroundSierra Leone has one of the highest maternal mortality rates in the world. Encouraging the use of skilled birth attendance in health facilities is an important step in the endeavor to increase the number of safe deliveries. However, public trust in health facilities has been greatly damaged during the Ebola epidemic outbreak in Sierra Leone in 2014/2015, and little is known about external and intrinsic barriers to facility-based delivery (FBD) in the country since the end of the Ebola epidemic.MethodsWe conducted a qualitative study on FBD in Princess Christian Maternity Hospital, Freetown, which is the national referral maternity hospital in Sierra Leone. We performed six focus group discussions with providers, pregnant women and recent mothers surrounding experiences, attitudes and behaviors regarding FBD and potential barriers. Discussions were tape recorded, transcribed and evaluated through content analysis.ResultsWomen in our study were overall technically aware of the higher safety linked with FBD, but this often diverged from their individual desire to deliver in a supportive and trusted social and traditional environment. Close relatives and community members seemed to be highly influencial regarding birth practices. Many women associated FBD with negative staff attitudes and an undefined fear. Logistic issues regarding transportation problems or late referral from smaller health centers were identified as frequent barriers to FBD.ConclusionsMore supportive staff attitudes and acceptance of an accompanying person throughout delivery could be promising approaches to increase women’s confidence in FBDs. However, these approaches also imply revising health systems structures, like staff working conditions that are conducive for a friendly atmosphere, sufficient space in delivery wards allowing the women to bring a birth companion, or like the establishment of a reliable peripheral ambulance system to ensure transportation and fast referral.

Influenza vaccination in pregnancy: vaccine uptake, maternal and healthcare providers' knowledge and attitudes. A quantitative study.

BackgroundInfluenza during pregnancy is a potentially life threatening illness. There are limited data on influenza vaccination uptake and determinants of uptake in Irish obstetric populations.AimTo determine the uptake of influenza vaccination during pregnancy; determinants of vaccination uptake; knowledge, attitudes, and concerns of postnatal women; and knowledge and attitudes of healthcare professionals (HCPs) surrounding vaccination.Design & settingA quantitative study of postnatal women attending the Rotunda Hospital, a tertiary referral maternity hospital in Dublin, Ireland. A separate quantitative study conducted by the North Dublin City GP Training Programme surveyed GPs, pharmacists, and Rotunda Hospital clinical staff.MethodA paper-based survey was distributed to postnatal women. HCPs completed the survey via the online tool Survey Monkey.Results330 patient surveys were disseminated, with a 60.0% response rate. Of 198 responders, 109 (55.1%) were vaccinated against influenza. Non-professionals were less likely to be vaccinated (adjusted odds ratio [aOR] 0.29, 95% confidence interval [CI] = 0.09 to 0.89). Vaccination in previous pregnancy (aOR 5.2, 95% CI = 1.69 to 15.62) and information from an HCP were strongly associated with vaccination (aOR 12.8, 95% CI = 2.65 to 62.5). There was a 20.2% (n = 1180) response rate among HCPs. More GPs felt that it was their role to discuss vaccination (92.9%; n = 676), and offer to vaccinate women (91.7%; n = 666) than any other HCP.ConclusionProvision of information about the importance of vaccination against influenza and pertussis during pregnancy by HCPs and their consistent recommendations in support of vaccination were key determinants of vaccine uptake during pregnancy. The sociodemographic determinants of a woman’s vaccination status should be addressed in health promotion campaigns. Education of HCPs may address knowledge gaps surrounding vaccination.

The impact of hypertension, hemorrhage, and other maternal morbidities on functioning in the postpartum period as assessed by the WHODAS 2.0 36-item tool

ObjectiveTo assess the scores of postpartum women using the WHO Disability Assessment Schedule 2.0 36‐item tool (WHODAS‐36), considering different morbidities.MethodsSecondary analysis of a retrospective cohort of women who delivered at a referral maternity in Brazil and were classified with and without severe maternal morbidity (SMM). WHODAS‐36 was used to assess functioning in postpartum women. Percentile distribution of total WHODAS score was compared across three groups: Percentile (P)<10, 10<P<90, and P>90. Cases of SMM were categorized and WHODAS‐36 score was assessed according to hypertension, hemorrhage, or other conditions.ResultsA total of 638 women were enrolled: 64 had mean scores below P<10 (1.09) and 66 were above P>90 (41.3). Of women scoring above P>90, those with morbidity had a higher mean score than those without (44.6% vs 36.8%, P=0.879). Women with higher WHODAS‐36 scores presented more complications during pregnancy, especially hypertension (47.0% vs 37.5%, P=0.09). Mean scores among women with any complication were higher than those with no morbidity (19.0 vs 14.2, P=0.01). WHODAS‐36 scores were higher among women with hypertensive complications (19.9 vs 16.0, P=0.004), but lower among those with hemorrhagic complications (13.8 vs 17.7, P=0.09).ConclusionsComplications during pregnancy, childbirth, and the puerperium increase long‐term WHODAS‐36 scores, demonstrating a persistent impact on functioning among women, up to 5 years postpartum.

The impact of proteinuria on maternal and perinatal outcomes among women with pre-eclampsia.

To assess the impact of proteinuria on pregnancy outcomes among women with pre-eclampsia. The present retrospective cohort study included patients with pre-eclampsia who delivered at a referral maternity hospital in Brazil between January 1, 2009, and December 31, 2013. Patients were stratified into three groups based on 24-hour urinary protein excretion during pregnancy: mild (0.3-<2.0g), severe (2.0-<5.0g), and massive (≥5.0g). There were 293 patients included in the study; 88, 129, and 76 had mild, severe, and massive proteinuria, respectively. Chronic hypertension was the most frequent pre-existing condition among all women (86 [29.4%]). The mean pregnancy duration at the onset of maternal pre-eclampsia was longest in the mild group compared and decreased with increasing proteinuria severity (P<0.001). Preterm delivery was recorded among 205 of 293 (70.0%) neonates; there were 66 (22.5%) neonates that were preterm and in the massive proteinuria group. The incidence of severe pre-eclampsia was lowest in the mild proteinuria group (P=0.002) and tended to occur at 34weeks. Cesarean delivery rates exceeded 80.0% in all groups. Most patients assessed at 40-60days postpartum remained proteinuric (40/61[66%]). Quantifying the severity of proteinuria could identify a subgroup of women with pre-eclampsia at increased risk of adverse outcomes.

Maternal critical care: Informing and influencing local commissioners

Background Relatively little is known about women who receive higher levels of care within maternity services, such as women with unanticipated pregnancy complications, high-risk pregnancies, complex maternal medical conditions and/or obstetric complications, and women who are or become critically ill. Aim To inform local health commissioners on the complexity of activity in a tertiary referral maternity and neonatal service. Methods A retrospective audit was completed, applying a local modification of the Intensive Care Society's levels of support for critical care agreed by obstetric, anaesthetic and midwifery teams. The audit included 525 women cared for in the designated critical care rooms over 1 year. Findings The findings show that haemorrhage (40%), hypertensive disorders (16%) and sepsis (12%) were the main reasons for maternal critical care, with 44% of women requiring levels 2 and 3 critical care. This audit confirmed adequate, equitable provision of appropriate maternal critical care, but identified a need for written guidance and training programmes on the transfer of critically ill pregnant or postpartum women. Conclusions This audit found that a standardised approach to local and regional data collection and agreed definitions of maternal critical care levels were essential for effective commissioning of maternity services to ensure funding by the local commissioning group is influenced by acuity and not births alone.

Medical Simulation as a Vital Adjunct to Identifying Clinical Life-Threatening Gaps in Austere Environments

BackgroundMaternal mortality and morbidity are major causes of death in low-resource countries, especially those in Sub-Saharan Africa. Healthcare workforce scarcities present in these locations result in poor perioperative care access and quality. These scarcities also limit the capacity for progressive development and enhancement of workforce training, and skills through continuing medical education. Newly available low-cost, in-situ simulation systems make it possible for a small cadre of trainers to use simulation to identify areas needing improvement and to rehearse best practice approaches, relevant to the context of target environments. MethodsNurse anesthetists were recruited throughout Sierra Leone to participate in simulation-based obstetric anesthesia scenarios at the country's national referral maternity hospital. All subjects participated in a detailed computer assisted training program to familiarize themselves with the Universal Anesthesia Machine (UAM). An expert panel rated the morbidity/mortality risk of pre-identified critical incidents within the scenario via the Delphi process. Participant responses to critical incidents were observed during these scenarios. Participants had an obstetric anesthesia pretest and post-test as well as debrief sessions focused on reviewing the significance of critical incident responses observed during the scenario. Results21 nurse anesthetists, (20% of anesthesia providers nationally) participated. Median age was 41 years and median experience practicing anesthesia was 3.5 years. Most participants (57.1%) were female, two-thirds (66.7%) performed obstetrics anesthesia daily but 57.1% had no experience using the UAM. During the simulation, participants were observed and assessed on critical incident responses for case preparation with a median score of 7 out of 13 points, anesthesia management with a median score of 10 out of 20 points and rapid sequence intubation with a median score of 3 out of 10 points. ConclusionThis study identified substantial risks to patient care and provides evidence to support the feasibility and value of in-situ simulation-based performance assessment for identifying critical gaps in safe anesthesia care in the low-resource settings. Further investigations may validate the impact and sustainability of simulation based training on skills transfer and retention among anesthesia providers low resource environments.