Safe Childbirth Research Articles

Readiness of health facilities to provide safe childbirth in Liberia: a cross-sectional analysis of population surveys, facility censuses and facility birth records

BackgroundThe provision of quality obstetric care in health facilities is central to reducing maternal mortality, but simply increasing childbirth in facilities not enough, with evidence that many facilities in sub-Saharan Africa do not fulfil even basic requirements for safe childbirth care. There is ongoing debate on whether to recommend a policy of birth in hospitals, where staffing and capacity may be better, over lower level facilities, which are closer to women’s homes and more accessible. Little is known about the quality of childbirth care in Liberia, where facility births have increased in recent decades, but maternal mortality remains among the highest in the world. We will analyse quality in terms of readiness for emergency care and referral, staffing, and volume of births.MethodsWe assessed the readiness of the Liberian health system to provide safe care during childbirth use using three data sources: Demographic and Health Surveys (DHS), Service Availability and Readiness Assessments (SARA), and the Health Management Information System (HMIS). We estimated trends in the percentage of births by location and population caesarean-section coverage from 3 DHS surveys (2007, 2013 and 2019–20). We examined readiness for safe childbirth care among all Liberian health facilities by analysing reported emergency obstetric and neonatal care signal functions (EmONC) and staffing from SARA 2018, and linking with volume of births reported in HMIS 2019.ResultsThe percentage of births in facilities increased from 37 to 80% between 2004 and 2017, while the caesarean section rate increased from 3.3 to 5.0%. 18% of facilities could carry out basic EmONC signal functions, and 8% could provide blood transfusion and caesarean section. Overall, 63% of facility births were in places without full basic emergency readiness. 60% of facilities could not make emergency referrals, and 54% had fewer than one birth every two days.ConclusionsThe increase in proportions of facility births over time occurred because women gave birth in lower-level facilities. However, most facilities are very low volume, and cannot provide safe EmONC, even at the basic level. This presents the health system with a serious challenge for assuring safe, good-quality childbirth services.

Battling Hypotension in Cesarean Section

Perhaps the greatest day in a mother's life is the birth of her child. As a father of two, I will never forget those two drastically different, yet equally beautiful moments. In each circumstance, the obstetricians, nurses, anesthesia providers, and technicians all worked seamlessly to provide a safe and enjoyable childbirth experience for our new and growing family. One key element of the childbirth experience is maternal pain control. Depending on several factors, the parturient may receive an epidural, a spinal, a combined spinal/epidural, IV analgesics or perhaps nothing at all. One key commonality after any anesthetic administration is its propensity to cause hypotension, which is usually most profound after spinal anesthesia (SA). SA is the preferred method during elective cesarean sections due to the rapid and predictable onset and duration of action of local anesthetics injected directly into the cerebrospinal fluid. Immediately after SA is administered, the patient is helped to lay supine which assists the hyperbaric local anesthetic to move with gravity and rise cephalad from the lower lumber injection site (L3-L5) towards the desired T4 vertebra. While marching up those 12 dermatome levels, the local anesthetic quickly begins to attenuate sympathetic tone at every level along the way. Depending on the health of the patient's cardiovascular system, intravascular volume status and other factors, the sympathectomy and subsequent vasodilation can result in significant and symptomatic hypotension, causing a vast array of symptoms such as maternal nausea, vomiting, dizziness, and cardiovascular collapse as well as fetal acidosis and decreased Apgar scores. Preanesthesia fluid boluses are commonly administered in hopes to increase intravascular volume and lessen the severity of hypotension, but its effectiveness is unreliable. Acute arterial vasodilation is the primary cause of hypotension after SA. Intravenous vasoactive medications such as phenylephrine and ephedrine offer the fastest and most effective means of arterial vasoconstriction and subsequent correction of blood pressure; yet healthcare providers will always continue to search for alternative and less invasive methods of preventing and/or treating hypotension after SA.

The status quo and influencing factors of knowledge, attitude and practice of obstetric staff on the safe childbirth checklist

Practical Guidelines for Safe Childbirth Checklist has not been widely used in medical institutions at all levels in China. This study aims to understand the current status of knowledge, attitude and practice of obstetric medical staff toward the Safe Childbirth Checklist and analyze its influencing factors to provide a reference for establishing the promotion of the checklist. Convenience sampling was used in a cross-sectional survey of 685 obstetric medical staff in Chongqing using a self-designed questionnaire to analyze their knowledge, attitude and practice of the checklist. The scores of knowledge, attitude and practice of obstetric medical staff on the checklist were 29.96 ± 5.44, 62.87 ± 9.11, and 37.74 ± 6.82, respectively. Occupation and hospital level were influencing factors of the knowledge and practice scores, while length of service was the only influencing factor of the knowledge score. Education was the influencing factor of attitude score. The total effects of the knowledge, facilitation and inhibition dimensions on practice were 0.671, 0.263 and -0.135, respectively. Mediating effects presented in the facilitation and inhibition of attitude in safe childbirth. Obstetrics medical staff know the checklist well, however, their attitudes and practices need to be improved. Managers should take targeted measures to strengthen the attitudes and practices of obstetric medical staff toward safe childbirth and promote the use of the checklist, thus providing a powerful safeguard for higher delivery quality and safer delivery.

Choosing cesarean section over natural birth: Challenges of decision making among pregnant women with pre-eclampsia in Ado-Ekiti.

Although Caesarean section has greatly improved obstetric care throughout the world, there is a great aversion to caesarean section in developing countries. This study was carried out to examine the rate at which pregnant women with Pre-eclampsia decide to choose caesarean section over natural birth. A descriptive study was conducted among a sample of 112 pregnant women with Pre-eclampsia, aged 18-40years, whose gestation period has exceeded 20weeks and are registered in the hospitals. The sample selection was purposive. Data collection was done through self-administered structured questionnaire. Data analysis was presented using simple percentages. 94% of respondents had no prior information about Pre-eclampsia and its associated complications. Pre-eclampsia has a prevalence rate of 12.3% among respondents in Ado-Ekiti as at the time this study was conducted. 38% of respondent favored caesarean section because they believed it is safer, less painful with little or no complications. If caesarean section is given as an only medical option for safe childbirth to respondents who preferred natural birth, 46.4% would opt for religious interventions while 10.7% would opt for traditional healthcare. Respondents who preferred natural birth would not choose caesarean section because of fear, cultural belief, religious beliefs and the cost. Level of education, religion and employment status were found to influence respondents' decision to choose. Hence the need to encourage research in awareness creation, patient education and best ways to assist patients decide on mode of delivery and plan on how to finance treatment.

Shackling and pregnancy care policies in US prisons and jails.

The number of incarcerated women in the United States has risen exponentially. Many are of childbearing age with 3-4% being pregnant at intake. Despite the need for comprehensive pregnancy-related health care in prisons and jails, there is no oversight that requires adherence to the established standards. The objective of this study was to assess prison and jail pregnancy policies and practices with an emphasis on restraint use and compliance with anti-shackling legislation. We conducted a survey of 22 state prisons and six jails, including the five largest jails, from 2016-2017 regarding pregnancy policies and practices including restraint use, prenatal care, delivery and birth, and other pregnancy accommodations. We compared reported restraint policies to state legislation at the time of the survey. Data indicate that pregnancy policies and services in prisons and jails vary and compliance inconsistencies with anti-shackling legislation exist. A third of the prisons and half of the jails did not have accredited health care services. All study facilities provided prenatal vitamins and most provided supplemental snacks. Most facilities stationed an officer inside the hospital room during labor and delivery, but nearly one-third of facilities did not require a female-identifying officer. Limited oversight and standardization of carceral health care and accommodations for pregnant people lead to variability in prisons and jails. Prisons and jails should adopt and implement standards of care guidelines to ensure the safety and well-being of pregnant people who have unique healthcare needs. Incarcerated pregnant people should be viewed as expectant parents in need of comprehensive health care, rather than as criminals who forfeited their right to a safe, respectful, and humane childbirth.

Knowledge, Attitude, and Practice among Palestinian Mothers Attending the Governmental Primary Health Care Centers Regarding Preconception Care Services

Background: Preconception care considers the backbone for safe pregnancy and childbirth outcomes. Therefore, early preconception care provided by healthcare professionals before pregnancy is crucial in reducing childbirth morbidity and mortality rates. This study aims to assess mothers' knowledge, attitude, and practice (KAP) about preconception care at governmental primary health care clinics in the Gaza Strip. Methods: A descriptive cross-sectional study was conducted in seven primary health care centers and data was collected using a self-administered questionnaire (including 3-point Likert Scale). A convenience sample of 372 mothers aged from 16 to 49 years, and who visit governmental clinics as a routine followup were selected. Results: the overall level of practices regarding preconception care was (75%) was reported about the importance of eating a wellshowed a high attitude level in terms of the importance of Conclusion: In Gaza Strip, mothers have fair knowledge and attitude levels but low level of practice regarding preconception care which shows that there is an opportunity in existing circumstances for the implementation of interventions targeting predictors for increased knowledge and uptake of preconception care.

Factors influencing birth preparedness and complication readiness among childbearing age women in Thatta district, Sindh.

Birth preparedness and complication readiness (BPCR) is a broad system to increase the practice of trained health provision at the time of childbirth and the key interventions to decrease mothers' and newborns' death. However, its status and influencing factors have not been well studied at different levels in the study area. The current study aimed to assess the BPCR status and explore its associated factors influencing BPCR among childbearing age women in Thatta, District of Sindh. This community-based cross-sectional study was conducted among 770 recently delivered mothers from October 2016 -September 2017, recruited using a multistage cluster sampling technique. A structured validated close-ended questionnaire measuring BPCR knowledge and practices was used for the interviews. The results were analyzed by means of the Chi-square test, and a binary logistic regression model was used to determine the factors influencing BPCR. The overall response rate was 94.6%, with a low BPCR status. Out of 770 participants, only 163 (21.2%) were well prepared, while 607 (78.8%) were not prepared for safe childbirth and its complications. A small proportion of women knew about the serious warning signs of pregnancy, labour, childbirth and the postpartum period (16.2%), (15.3%) and (22.7%) respectively. Antenatal care (ANC) checkup (P < 0.001), cost of ANC checkup (p = 0.016), place of birth (p = 0.014), awareness of serious warning signs during pregnancy (p = 0.001) and awareness of serious warning signs during the postpartum period (p < 0.001) were found to be significant predictors of BPCR. The proportion of women who were well prepared for birth and its complications was low. It is recommended to organize community-based education campaigns and improve the quality of MNCH services at every level to increase BPCR among women in Sindh.

Community perception of barriers and facilitators to institutional delivery care-seeking behavior in Northwest Ethiopia: a qualitative study

BackgroundInstitutional delivery care-seeking behavior is considered a crucial step in preventing maternal and child death. However, the barriers and facilitators related to institutional delivery care-seeking behavior in the study area were not studied very in-depth. Hence, the current study aimed to explore barriers and enablers of institutional delivery care-seeking behavior in Northwest Ethiopia.MethodsA descriptive phenomenological qualitative inquiry was used. The data was collected by using a piloted interview guide. We collected data using in-depth interviews among women and men; and key informant interviews from the Female health development army and health extension workers in November and December 2019. Framework analysis was utilized for the analysis of the data.ResultsThis study found out the potential factors which hinder and facilitate institutional delivery. The barriers to institutional delivery included the belief that pregnancy and childbirth are normal and business of women’s, women’s preference of home delivery with traditional attendants, family influence, fear of bad behavior of health care workers, and lack of resources. The facilitators were free maternal services (ambulance services and maternity services), having the experience of safe childbirth at health facilities, and women’s health development army linkage with health extension workers.ConclusionThis study provides evidence that low-risk perception of home delivery, socio-cultural influences, service provision modalities, and financial factors were the determinants of institutional delivery service use. Therefore, a stage-matched intervention shall be designed to improve the uptake of institutional delivery service use.

Pregnancy in paroxysmal nocturnal hemoglobinuria: from survival to life

Pregnancy in paroxysmal nocturnal hemoglobinuria (PNH) patients has historically been a high-risk situation. The combination of chronic complement-mediated hemolysis caused by the disease and physiological activation of the complement system during pregnancy, significantly worsened the prognosis for the life. For a long time, there were no effective methods for the PNH treatment, and pregnancy in patients seemed to be extremely risky, as it significantly increased the risk of life-threatening complications. The advent of targeted therapy with eculizumab turned the prognosis of this disease upside down: patients began not only to survive, but also to live comparable to healthy people. A comparative analysis of the course and outcomes of pregnancy in patients with PNH treated with eculizumab and in patients without targeted therapy was carried out. The study was to evaluate the course and outcomes of pregnancy in patients with PNH, depending on the therapeutic approach. We analyzed data from 57 pregnancies in 49 women (31 used eculizumab, 26 with supportive care only) observed at the Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology or with remote consultation (23 clinics from 19 cities of Russia). The high probability of pregnancy complications and its adverse outcomes outside of targeted therapy indicates the vital need for its use: all observations were accompanied by complications of varying severity. The course of pregnancy with the eculizumab is generally more favorable: an apparently higher rate of live births and a lower likelihood of complications are registered. Without increasing the incidence of complications, eculizumab significantly improves pregnancy outcomes for both mother and fetus, and does not adversely affect the health of newborns. Thus, eculizumab allows not only to increase the survival rate of patients with PNH, but also to comprehensively improve their quality of life, including the possibility of safe childbirth.

Can maternal hormones play a significant role in delivery mode?

The aim of this study was primarily to evaluate the levels of progesterone, oestradiol and relaxin during different delivery modes and secondarily to assess specific traits and changes in maternal pelvic dimensions during pregnancy and childbirth, in correlation with foetal size and maternal hormonal profile. Nulliparous women (n = 448) were evaluated at three different stages, during first trimester, at the time of admission for childbirth and finally just before childbirth. Each examination included clinical internal pelvimetry, blood sample collection for defining the hormones levels in peripheral maternal circulation and ultrasonographic measurements of specific variables of the pubic symphysis and the foetus. We included 304 nulliparous women divided in three groups. According to our results, there was statistically significant difference at the mean progesterone, oestradiol and relaxin range during different modes of childbirth (p-value < .01). We also found significant correlation between the newborn’s weight and the changes in pubic symphysis dimensions. However, no significant association was noted between maternal hormones studied and the changes in pelvic dimensions. IMPACT STATEMENT What is already known on this subject? Mode of childbirth can be affected by various aspects, like maternal pelvic anatomy, foetal size and hormonal status at the time of labour. Hormonal fluctuations along with mechanical forces caused by the foetus are believed to lead to morphological alterations to promote natural vaginal childbirth. What do the results of this study add? Our results clearly showed that successful vaginal delivery is characterised by the prevalence of a hyperoestrogenic environment with higher values of intrapartum oestradiol range and significant increase in maternal serum relaxin levels. We also proved that progesterone levels do not decrease during vaginal childbirth, and we concluded that foetal size seems to be the most crucial factor causing alterations in maternal pelvis during parturition. What are the implications of these findings for clinical practice and further research? Our findings could form part of a set of key factors included in future algorithms or computerised biomechanical models for predicting potential childbirth mode. Larger multicenter studies should confirm our results and evaluate their clinical significance in the decision making to ensure safe childbirth and optimal maternal and perinatal outcomes.

Are sexual and reproductive health and rights taught in medical school? Results from a global survey.

Our aim was to investigate the inclusion of sexual and reproductive health and rights (SRHR) topics in medical curricula and the perceived need for, feasibility of, and barriers to teaching SRHR. We distributed a survey with questions on SRHR content, and factors regulating SRHR content, to medical universities worldwide using chain referral. Associations between high SRHR content and independent variables were analyzed using unconditional linear regression or χ2 test. Text data were analyzed by thematic analysis. We collected data from 219 respondents, 143 universities and 54 countries. Clinical SRHR topics such as safe pregnancy and childbirth (95.7%) and contraceptive methods (97.2%) were more frequently reported as taught compared with complex SRHR topics such as sexual violence (63.8%), unsafe abortion (65.7%), and the vulnerability of LGBTQIA persons (23.2%). High SRHR content was associated with high-income level (P=0.003) and low abortion restriction (P=0.042) but varied within settings. Most respondents described teaching SRHR as essential to the health of society. Complexity was cited as a barrier, as were cultural taboos, lack of stakeholder recognition, and dependency on fees and ranking.

Predictors of childbirth services in Indonesia

The Government of Indonesian implemented maternal health service programs to minimize at-home childbirth services and increase mothers' utilization of its services. There is not enough evidence these policies are effectively decreasing the maternal mortality rate. Hence, this study aimed to analyze the predictors of each specific childbirth services in Indonesia. This study used the secondary dataset of the 2012 Indonesian demographic data survey (IDHS). The sample was 17,769 women ages 15 to 49 years old. We performed logistic regression for the multivariate case to identify the predictors of childbirth service. Geographical, education, and economic condition significantly predict childbirth services. Women who are not residents tend to use a community-based facility than institutionalized health. Women with higher parity, inadequate knowledge on pregnancy danger signs, lower antenatal care visits, and never had any discussion with their husbands about the planned place of giving birth tend to prefer giving birth at home than health facilities. Women's decision to use a safe childbirth service is hindered by demanding access to reach institutionalized healthcare. Our findings highlighted the importance of women empowerment to enable women to utilize safe labor in a health facility.

The Relationship Between Knowledge and Regularity of Antenatal Care Visits During The Covid-19 Pandemic

Antenatal care (ANC) purpose to obtaining a safe and positive pregnancy and childbirth. Covid-19 pandemic bring an impact on the health sector, including ANC visits. This study purpose to analyze the relationship between knowledge with regularity of ANC visits for pregnant women in the third trimester during the Covid-19 pandemic in the work area of UPTD Puskesmas Karang Rejo. This research is a correlative analytical study with cross-sectional approach. The population were all pregnant women in third trimesters who did ANC with samples 37 respondents. The sampling technique was consecutive sampling. Data analysis using Spearman Rho statistical test. The result of bivariate analysis was p =0,001, and the coefficient value (r = 0,744) meaning there is a correlation between the knowledge and the regularity of ANC visit. Pregnant women are expected to always open mind to receiving the information that given by health workers to increase their knowledge about ANC visits so support and motivate to did ANC visit regularly.

Constructing evidence-based clinical intrapartum care algorithms for decision-support tools.

To describe standardised iterative methods used by a multidisciplinary group to develop evidence-based clinical intrapartum care algorithms for the management of uneventful and complicated labours. Singleton, term pregnancies considered to be at low risk of developing complications at admission to the birthing facility. Health facilities in low- and middle-income countries. Literature reviews were conducted to identify standardised methods for algorithm development and examples from other fields, and evidence and guidelines for intrapartum care. Searches for different algorithm topics were last updated between January and October 2020 and included a combination of terms such as 'labour', 'intrapartum', 'algorithms' and specific topic terms, using Cochrane Library and MEDLINE/PubMED, CINAHL, National Guidelines Clearinghouse and Google. Nine algorithm topics were identified for monitoring and management of uncomplicated labour and childbirth, identification and management of abnormalities of fetal heart rate, liquor, uterine contractions, labour progress, maternal pulse and blood pressure, temperature, urine and complicated third stage of labour. Each topic included between two and four case scenarios covering most common deviations, severity of related complications or critical clinical outcomes. Intrapartum care algorithms provide a framework for monitoring women, and identifying and managing complications during labour and childbirth. These algorithms will support implementation of WHO recommendations and facilitate the development by stakeholders of evidence-based, up to date, paper-based or digital reminders and decision-support tools. The algorithms need to be field tested and may need to be adapted to specific contexts. Evidence-based intrapartum care clinical algorithms for a safe and positive childbirth experience.

The effect of backup midwife on maternal experience after vaginal childbirth - a qualitative study.

One of the goals of reproductive health enhancement is to ensure the desired experience of safe childbirth by reducing possible complications, fears, and worries about delivery by ongoing midwife backup care. This study explains women's experiences with a backup midwife during labor and childbirth. This was a qualitative study involving 19 women who had natural childbirth in Hamadan, 2020. Purposeful sampling and data collection were performed using semi-structured in-depth interviews. Data were analyzed by conventional content analysis using MAXQDA software version 10. Data analysis showed three themes and six main categories. The themes included security, high-quality care, and respectful care, consisting of two main categories of perceived empowerment and support, physiological approach and reassuring care, and respect for the mother's privacy and optimal accountability. The presence of a backup midwife during labor caused a sense of security, control, and perceived empowerment, thus a positive childbirth experience. Therefore, it is necessary to train and employ midwifery in the healthcare system. It is recommended to train and employ midwifery graduates for this purpose and include it as one of the basic principles in the current planning to promote natural childbirth.

Associations of antenatal care visit with utilization of institutional delivery care services in Afghanistan: intersections of education, wealth, and household decision-making autonomy

BackgroundThe importance of antenatal care (ANC) visits in safe motherhood and childbirth is well-documented. However, less is known how social determinants of health interact with ANC visits in shaping the uptake of professional delivery care services in low-income countries. This study examines the associations of ANC visits with institutional delivery care utilization outcomes in Afghanistan. Further, we assess the extent to which ANC visits intersect with education, wealth, and household decision-making autonomy in predicting two outcomes of delivery care utilization- delivery at a health facility and delivery assisted by a skilled birth attendant.MethodsWe used data from the Afghanistan Demographic and Health Survey (AfDHS) 2015. The analytic sample included 15,590 women of reproductive age (15–49). We assessed the associations using logistic regression models, estimated the predicted probability of delivery care outcomes using statistical interactions, and presented estimates in margins plot.ResultsMultivariable adjusted analyses suggest that women who had 4 or more ANC visits were 5.7 times (95% CI = 4.78, 7.11; P < 0.05) more likely to use delivery care at a health facility and 6.5 times (95% CI = 5.23, 8.03; P < 0.05) more likely to have a delivery assisted by a skilled birth attendant compared to women who had no ANC visit. Estimates from models with statistical interactions of ANC visits with education, wealth, and decision-making autonomy suggest that women with higher social status were more advantageous in utilizing institutional delivery care services compared to women with lower levels of social status.ConclusionOur findings suggest that the associations of ANC visits with institutional delivery care services are stronger among women with higher social status. The results have implications for promoting safe motherhood and childbirth through improving women’s social status.

Individual and Community-Level Determinants of Institutional Delivery Services among Women in Bangladesh: A Cross-Sectional Study.

Background Improving maternal mortality attracts considerable interest with the critical invention through institutional delivery services (IDS) in reducing maternal death during delivery and ensuring safe childbirth. The influence of both individual and community-level factors is essential to using IDS. Problem Statement. Maternal death may occur at any time, but delivery without designated healthcare is by far the most dangerous time for both woman and her baby. Therefore, to combat the global burden of maternal mortality, it is necessary to ensure IDS worldwide. Objectives This study explores the current knowledge of individual and community-level covariates and examines their extent of influence on the utilization of IDS in Bangladesh. Methods Utilizing Bangladesh Demographic and Health Survey (BDHS) data, this study has used two-level random intercept binary logistic regression, together with the average annual rate of increase (AARI) in the utilization of IDS and related variables. Results This study found appreciable changes in seeking IDS, increases from 3.4% in 2007 to 51.9% in 2017, and half of the total deliveries (51%) took place in healthcare. About 26% of the total variation in the utilization of IDS is owing to differences across communities. Further, covariates including communities with higher educated women, higher utilization of ANC and access to media and at individual level, religion, maternal and parental education, wealth index, and mother-level factors (i.e., age at birth, BMI, occupation, ANC visit, birth order, own health care decision, pregnancy intention, and exposure to media) showed significant association with the utilization of IDS. Conclusion This study observed the association between individual and community-level factors and IDS uptake. Thus, any future strategies must address individual level and community-level challenges and undertake a multisectoral approach to enhance the uptake of IDS.

Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study

ABSTRACT Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study’s programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen – safe and respectful clinical childbirth care – is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants’ motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.

Implementing the WHO Safe Childbirth Checklist modified for preterm birth: lessons learned and experiences from Kenya and Uganda

BackgroundThe WHO Safe Childbirth Checklist (SCC) contains 29 evidence-based practices (EBPs) across four pause points spanning admission to discharge. It has been shown to increase EBP uptake and has been tailored to specific contexts. However, little research has been conducted in East Africa on use of the SCC to improve intrapartum care, particularly for preterm birth despite its burden. We describe checklist adaptation, user acceptability, implementation and lessons learned.MethodsThe East Africa Preterm Birth Initiative (PTBi EA) modified the SCC for use in 23 facilities in Western Kenya and Eastern Uganda as part of a cluster randomized controlled trial evaluating a package of facility-based interventions to improve preterm birth outcomes. The modified SCC (mSCC) for prematurity included: addition of a triage pause point before admission; focus on gestational age assessment, identification and management of preterm labour; and alignment with national guidelines. Following introduction, implementation lasted 24 and 34 months in Uganda and Kenya respectively and was supported through complementary mentoring and data strengthening at all sites. PRONTO® simulation training and quality improvement (QI) activities further supported mSCC use at intervention facilities only. A mixed methods approach, including checklist monitoring, provider surveys and in-depth interviews, was used in this analysis.ResultsA total of 19,443 and 2229 checklists were assessed in Kenya and Uganda, respectively. In both countries, triage and admission pause points had the highest rates of completion. Kenya’s completion was greater than 70% for all pause points; Uganda ranged from 39 to 75%. Intervention facilities exposed to PRONTO and QI had higher completion rates than control sites. Provider perceptions cited clinical utility of the checklist, particularly when integrated into patient charts. However, some felt it repeated information in other documentation tools. Completion was hindered by workload and staffing issues.ConclusionThis study highlights the feasibility and importance of adaptation, iterative modification and complementary activities to reinforce SCC use. There are important opportunities to improve its clinical utility by the addition of prompts specific to the needs of different contexts. The trial assessing the PTBi EA intervention package was registered at ClinicalTrials.gov NCT03112018 Registered December 2016, retrospectively registered.

Weekend delivery and maternal-neonatal adverse outcomes in low-risk pregnancies in the United States: Apopulation-based analysis of 3-million live births.

Childbirth is the most common cause of hospital admission in the United States. Previous studies have shown that there might be a "weekend effect" in perinatal care, indicating that mothers and newborns whose deliveries occur during the weekends are at increased risk of having adverse outcomes. This study aims to isolate the association between the weekend delivery and maternal-neonatal adverse outcomes by investigating low-risk pregnancies in nationwide data. A population-based study of all low-risk pregnancies (in-hospital, nonanomalous, term, normal birthweight, and singleton) was conducted based on US national natality data in 2017. Four maternal outcomes (ICU admission, uterine rupture, blood transfusion, and perineal laceration) and three neonatal outcomes (5-minute Apgar <7, NICU admission, and neonatal death) were defined as adverse outcomes. Logistic regression analyses were conducted to determine the association, adjusting for 23 maternal and neonatal characteristics and risk factors. Among 3011577 low-risk pregnancies, 6.0% were reported to have at least one of the maternal-neonatal adverse outcomes. Weekend deliveries were significantly associated with six maternal-neonatal adverse outcomes with an exception of neonatal death. In general, weekend deliveries were 1.13 times significantly as likely to have any of seven maternal-neonatal adverse outcomes than weekday deliveries (OR 1.13, 95% CI 1.11-1.14), being attributed to adverse outcomes of more than 4500 mother-newborn pairs. Weekend delivery is a consistent risk factor for both mothers and babies at the national level. Furthermore, studies are needed about possible modifiable factors that mediate these associations to ensure safe childbirth regardless of the day of delivery.