WHO Reproductive Health Library Research Articles

A Systematic Review of Antenatal Risk Scoring Systems in India to Predict Adverse Neonatal Outcomes.

The purpose of antenatal care (ANC) is to identify 'at-risk' pregnant women, to provide quality care for all, and maximize the allocation of resources for those who need them the most. To address the synergistic effect of risk factors, clinicians across the globe developed antenatal scoring systems. This review aims to investigate various antenatal risk scoring systems developed and used in India to predict adverse neonatal outcome. We reviewed articles published between January 2000 and April 2020, which have either developed a scoring system or used a scoring system, among the Indian population. This systematic review is reported based on Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Prediction model study Risk Of Bias Assessment Tool (PROBAST) was employed for the assessment of the quality of included studies. Data sources such as Embase, MEDLINE/Pubmed, APA PsycExtra, PsycINFO, CINHAL Plus, Cochrane Library, IndMED, LILACS, Scopus, WHO Reproductive Health Library and Web of science were searched. An initial search retrieved a total of 6246 articles. This systematic review identified six studies, of which one study developed an antenatal scoring system and the other five studies used two antenatal systems for predicting adverse neonatal outcome. The study which developed a risk scoring system had a high risk of bias (ROB) and concern for applicability. The overall sensitivity of the antenatal scoring system was high (77.4%), but the specificity was low (45%). Similarly, the positive predictive value is low (15.3%), and the negative predictive value is high (94.2%). A meta-analysis was not conducted due to the heterogeneity of the studies and insufficient data. There is a need for a systematically developed antenatal scoring system for India. Such scoring systems can be promising in public health, proposing a paradigm shift in the implementation of effective mother and child health programmes locally as well as nationally. The online version contains supplementary material available at 10.1007/s13224-021-01484-z.

A systematic review of essential obstetric and newborn care capacity building in rural sub-Saharan Africa.

Progress in maternal survival in sub-Saharan Africa has been poor since the Millennium Declaration. This systematic review aims to investigate the presence and rigour of evidence for effective capacity building for Essential Obstetric and Newborn Care (EONC) to reduce maternal mortality in rural, sub-Saharan Africa, where maternal mortality ratios are highest globally. MEDLINE (1990-January 2014), EMBASE (1990-January 2014), and the Cochrane Library were included in our search. Key developing world issues of The Lancet and the British Journal of Obstetrics and Gynaecology, African Ministry of Health websites, and the WHO reproductive health library were searched by hand. Studies investigating essential obstetric and newborn care packages in basic and comprehensive care facilities, at community and institutional level, in rural sub-Saharan Africa were included. Studies were included if they reported on healthcare worker performance, access to care, community behavioural change, and emergency obstetric and newborn care. Data were extracted and all relevant studies independently appraised using structured abstraction and appraisal tools. There is moderate evidence to support the training of healthcare workers of differing cadres in the provision of emergency obstetric and newborn services to reduce institutional maternal mortality and case-fatality rates in rural sub-Saharan Africa. Community schemes that sensitise and enable access to maternal health services result in a modest rise in facility birth and skilled birth attendance in this rural setting. Essential Obstetric and Newborn Care has merit as an intervention package to reduce maternal mortality in rural sub-Saharan Africa.

A Review of the Impact of Different Social Policy Incentives to Accelerate Population Growth Rate

Context: Cash payments or other incentive policies to improve population growth rate have been used for many years; but the efficiency of these policies has not yet been fully understood. We provide a brief background to different incentive population policies for accelerating birth rate and its underlying rationale and consequences. Evidence Acquisition: For our search strategy, we reviewed the J store, Medline, science direct, ISI database, and the WHO Reproductive Health Library. The study comprised all published and unpublished accounts on cash and other incentive programs, with especial reference to key considerations on the use of these policies. The majority of studies have been conducted in developed countries and policies are focused on addressing basic factors such as women’s decision making on childbearing, poverty, or western life style. Results: In general, there are four different types of incentive policy instruments that can potentially influence childbearing: direct cash payments such as baby bonus payments and family allowances, indirect transfers such as tax exemptions, housing policies, health care or child tax credits, creating better working conditions for mothers like improving work–family compatibility such as maternity and paternity leave with or without salary-maintenance, or availability, acceptability, accessibility of high quality and inexpensive nursery in the workplace, and inadvertent policies such as new graduate recruitment system which help young people find regular jobs, and schools could act as go-betweens in the recruitment process since employers prefer hiring recent graduates. Conclusions: We conclude that policies aimed at reducing the incompatibility between work and the factors associated with mothers' roles such as maternity leaves, childcare, and early education affecting women’s childbearing and younger age pregnancies. However, ongoing researches will shed more light on the efficacy of each incentive policies in the context of Iran.

Timing of cord clamping in very preterm infants: more evidence is needed

In December 2012, the American College of Obstetricians and Gynecologists published a Committee Opinion entitled "Timing of umbilical cord clamping after birth." It stated that "evidence exists to support delayed cord clamping in preterm infants, when feasible. The single most important benefit for preterm infants is the possibility for a nearly 50% reduction in IVH." However, the Committee Opinion added that the ideal timing of umbilical cord clamping has yet to be determined and recommended that large clinical trials be conducted in the most preterm infants. Published randomized controlled trials include <200 infants of <30 weeks' gestation, with assessments of neurodevelopmental outcome in less than one-half of the children. This is a major gap in the evidence. Without reliable data from randomized controlled trials that optimally include childhood follow-up evaluations, we will not know whether delayed cord clamping may do more overall harm than good. Ongoing trials of delayed cord clamping plan to report childhood outcomes in >2000 additional very preterm infants. Current recommendations may need to change when these results become available. Greater international collaboration could accelerate resolution of whether this promising intervention will improve disability-free survival in about 1 million infants who will be born very preterm globally each year.

Improved quality of management of eclampsia patients through criteria based audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. Bridging the quality gap

BackgroundCriteria-based audits (CBA) have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the use of a CBA to improve quality of care among eclampsia patients admitted at a University teaching hospital in Dar es Salaam Tanzania.ObjectiveThe prevalence of eclampsia in MNH is high (≈6%) with the majority of cases arriving after start of convulsions. In 2004–2005 the case-fatality rate in eclampsia was 5.1% of all pregnant women admitted for delivery (MNH obstetric data base). A criteria-based audit (CBA) was used to evaluate the quality of care for eclamptic mothers admitted at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania after implementation of recommendations of a previous audit.MethodsA CBA of eclampsia cases was conducted at MNH. Management practices were evaluated using evidence-based criteria for appropriate care. The Ministry of Health (MOH) guidelines, local management guidelines, the WHO manual supplemented by the WHO Reproductive Health Library, standard textbooks, the Cochrane database and reviews in peer reviewed journals were adopted. At the initial audit in 2006, 389 case notes were assessed and compared with the standards, gaps were identified, recommendations made followed by implementation. A re-audit of 88 cases was conducted in 2009 and compared with the initial audit.ResultsThere was significant improvement in quality of patient management and outcome between the initial and re-audit: Review of management plan by senior staff (76% vs. 99%; P=0.001), urine for albumin test (61% vs. 99%; P=0.001), proper use of partogram to monitor labour (75% vs. 95%; P=0.003), treatment with steroids for lung maturity (2.0% vs. 24%; P=0.001), Caesarean section within 2 hours of decision (33% vs. 61%; P=0.005), full blood count (28% vs. 93%; P=0.001), serum urea and creatinine (44% vs. 86%; P=0.001), liver enzymes (4.0% vs. 86%; P=0.001), and specialist review within 2 hours of admission (25% vs. 39%; P=0.018). However, there was no significant change in terms of delivery within 24 hours of admission (69% vs. 63%; P=0.33). There was significant reduction of maternal deaths (7.7% vs. 0%; P=0.001).ConclusionCBA is applicable in low resource setting and can help to improve quality of care in obstetrics including management of pre-eclampsia and eclampsia.

A cluster randomized controlled trial to evaluate the effectiveness of the clinically integrated RHL evidence -based medicine course

Background and objectivesEvidence-based health care requires clinicians to engage with use of evidence in decision-making at the workplace. A learner-centred, problem-based course that integrates e-learning in the clinical setting has been developed for application in obstetrics and gynaecology units. The course content uses the WHO reproductive health library (RHL) as the resource for systematic reviews. This project aims to evaluate a clinically integrated teaching programme for incorporation of evidence provided through the WHO RHL. The hypothesis is that the RHL-EBM (clinically integrated e-learning) course will improve participants' knowledge, skills and attitudes, as well as institutional practice and educational environment, as compared to the use of standard postgraduate educational resources for EBM teaching that are not clinically integrated.MethodsThe study will be a multicentre, cluster randomized controlled trial, carried out in seven countries (Argentina, Brazil, Democratic Republic of Congo, India, Philippines, South Africa, Thailand), involving 50-60 obstetrics and gynaecology teaching units. The trial will be carried out on postgraduate trainees in the first two years of their training. In the intervention group, trainees will receive the RHL-EBM course. The course consists of five modules, each comprising self-directed e-learning components and clinically related activities, assignments and assessments, coordinated between the facilitator and the postgraduate trainee. The course will take about 12 weeks, with assessments taking place pre-course and 4 weeks post-course. In the control group, trainees will receive electronic, self-directed EBM-teaching materials. All data collection will be online.The primary outcome measures are gain in EBM knowledge, change in attitudes towards EBM and competencies in EBM measured by multiple choice questions (MCQs) and a skills-assessing questionniare administered eletronically. These questions have been developed by using questions from validated questionnaires and adapting them to the current course. Secondary outcome measure will be educational environment towards EBM which will be assessed by a specifically developed questionnaire.Expected outcomesThe trial will determine whether the RHL EBM (clinically integrated e-leraning) course will increase knowledge, skills and attitudes towards EBM and improve the educational environment as compared to standard teaching that is not clinically integrated. If effective, the RHL-EBM course can be implemented in teaching institutions worldwide in both, low-and middle income countries as well as industrialized settings. The results will have a broader impact than just EBM training because if the approach is successful then the same educational strategy can be used to target other priority clinical and methodological areas.Trial RegistrationACTRN12609000198224

O15 Evidence based healthcare and the WHO-Reproductive Health Library: is the common obstetrician/gynaecologist aware?

O15 Evidence based healthcare and the WHO-Reproductive Health Library: is the common obstetrician/gynaecologist aware?

Survey of knowledge and perception on the access to evidence-based practice and clinical practice change among maternal and infant health practitioners in South East Asia

BackgroundEvidence-based practice (EBP) can provide appropriate care for women and their babies; however implementation of EBP requires health professionals to have access to knowledge, the ability to interpret health care information and then strategies to apply care. The aim of this survey was to assess current knowledge of evidence-based practice, information seeking practices, perceptions and potential enablers and barriers to clinical practice change among maternal and infant health practitioners in South East Asia.MethodsQuestionnaires about IT access for health information and evidence-based practice were administered during August to December 2005 to health care professionals working at the nine hospitals participating in the South East Asia Optimising Reproductive and Child Health in Developing countries (SEA-ORCHID) project in Indonesia, Malaysia, Thailand and The Philippines.ResultsThe survey was completed by 660 staff from six health professional groups. Overall, easy IT access for health care information was available to 46% of participants. However, over a fifth reported no IT access was available and over half of nurses and midwives never used IT health information. Evidence-based practice had been heard of by 58% but the majority did not understand the concept. The most frequent sites accessed were Google and PubMed. The Cochrane Library had been heard of by 47% of whom 51% had access although the majority did not use it or used it less than monthly. Only 27% had heard of the WHO Reproductive Health Library and 35% had been involved in a clinical practice change and were able to identify enablers and barriers to change. Only a third of participants had been actively involved in practice change with wide variation between the countries. Willingness to participate in professional development workshops on evidence-based practice was high.ConclusionThis survey has identified the need to improve IT access to health care information and health professionals' knowledge of evidence-based health care to assist in employing evidence base practice effectively.

Acceptance of evidence-based reproductive health care among postgraduate specialist trainees in Nigeria

Objective To assess the perception and practice of evidence-based reproductive health care among Nigerian postgraduate specialist trainee doctors. Method A questionnaire survey of 326 Nigerian postgraduate specialist trainee doctors involved in reproductive health care was undertaken during training workshops on evidence-based medicine. Results Most respondents were familiar with evidence-based medicine (96.6%) and agreed that it would improve patient care (95.1%). Only 38.3% had ever received training on evidence-based medicine. Awareness and utilization of resources for evidence-based medicine were low; only 18.7% and 28.2% had ever used the Cochrane Library or the WHO Reproductive Health Library, respectively. Understanding of technical terms related to evidence-based medicine was poor. Lack of access to evidence was the most common constraint to the practice of evidence-based reproductive health care. Conclusion Nigerian postgraduate specialist trainee doctors are positively disposed to evidence-based reproductive health care but their understanding of the principles of evidence-based practice is inadequate.

Foreword: Maternal and childbirth health systematic reviews

Foreword: Maternal and childbirth health systematic reviews

Cluster Randomized Trial of an Active, Multifaceted Educational Intervention Based on the WHO Reproductive Health Library to Improve Obstetric Practices

The hypothesis underlying this study was that hospital obstetrical practices can be improved by interactive workshops that promote the use of evidence-based measures based on the World Health Organization's Reproductive Health Library (RHL). The RHL is an annually updated electronic publication featuring Cochrane reviews in the area of reproductive health along with expert commentary, practical guidance documents, and various aids such as educational videos. Participating in the trial were 22 hospitals in Mexico City and 18 in northeast Thailand, whose maternity units conducted more than a thousand deliveries each year, and which had no direct affiliation with a university or other academic or research facility. Three workshops were held during a 6-month period: the first provided information about the project and principles of evidence-based decision-making; the second focused on RHL content; and the third concerned how best to implement desired changes. A stratified cluster randomized design took country, type of hospital, and number of births per year into account. The chief outcome measures were changes in 10 clinical practices as recommended in the RHL, implemented within 4 to 6 months after the third workshop. The intervention failed to influence targeted practices in any consistent or substantive way. Three of the 10 practices (iron/folate supplementation, postnatal uterotonic use, breast feeding on demand) already were part of the practice regimen, and it proved impractical to measure external cephalic version. Selective rather than routine episiotomy was performed more often in the intervention hospitals than in control hospitals. In Mexico, antibiotics tended to be used more at the time of cesarean delivery. No significant differences were documented in companionship during labor, the use of magnesium sulfate to treat eclampsia, corticosteroid treatment of women delivering before 34 weeks' gestation, or the use of vacuum extraction. Awareness of the RHL increased substantially following the intervention at both study sites, as did its use. Despite the efficacy of active educational measures in expanding access to the RHL and promoting its use, this study failed to demonstrate lasting or substantial changes in reproductive medical practices. Within a 10- to 12-month time frame, at least, access to current knowledge of such practices apparently does not assure that they will become part of standard obstetrical care.

Cluster randomised trial of an active, multifaceted educational intervention based on the WHO Reproductive Health Library to improve obstetric practices

We conducted a trial to evaluate the effect of an active, multifaceted educational strategy to promote the use of the WHO Reproductive Health Library (RHL) on obstetric practices. Cluster randomised trial. The trial was assigned the International Standardised Randomised Controlled Trial Number ISRCTN14055385. Twenty-two hospitals in Mexico City and 18 in the Northeast region of Thailand. The intervention consisted primarily of three interactive workshops using RHL over a period of 6 months. The focus of the workshops was to provide access to knowledge and enable its use. A computer and support for using both the computer and RHL were provided at each hospital. The control hospitals did not receive any intervention. The main outcome measures were changes in ten selected clinical practices as recommended in RHL starting approximately four to six months after the third workshop. Clinical practice data were collected at each hospital from 1000 consecutively delivered women or for a 6-month period whichever was reached sooner. The active, multifaceted educational intervention we employed did not affect the ten targeted practices in a consistent and substantive way. Iron/folate supplementation, uterotonic use after birth and breastfeeding on demand were already frequently practiced, and we were unable to measure external cephalic version. Of the remaining six practices, selective, as opposed to routine episiotomy policy increased in the intervention group (difference in adjusted mean rate = 5.3%; 95% CI -0.1 to 10.7%) in Thailand, and there was a trend towards an increased use of antibiotics at caesarean section in Mexico (difference in adjusted mean rate = 19.0%; 95% CI: -8.0 to 46.0%). There were no differences in the use of labour companionship, magnesium sulphate use for eclampsia, corticosteroids for women delivering before 34 weeks and vacuum extraction. RHL awareness (24.8-65.5% in Mexico and 33.9-83.3% in Thailand) and use (4.8-34.9% in Mexico and 15.5-76.4% in Thailand) increased substantially after the intervention in both countries. The multifaceted, active strategy to provide health workers with the knowledge and skills to use RHL to improve their practice led to increased access to and use of RHL, however, no consistent or substantive changes in clinical practices were detected within 4-6 months after the third workshop.

Treatment of postpartum depression, part 2: a critical review of nonbiological interventions.

While postpartum depression is a common mental condition with significant burden, it often remains undiagnosed and untreated. The objective of this article is to critically review the literature to determine the current state of scientific knowledge related to the treatment of postpartum depression from a nonbiological perspective. Databases searched for this review included MEDLINE, PubMed, CINAHL, PsycINFO, EMBASE, ProQuest, the Cochrane Library, and the WHO Reproductive Health Library from 1966 to 2003. The search terms used were postpartum/postnatal depression and randomized controlled/clinical trials. Published peer-reviewed articles in English from 1990 to 2003 were included in the review, although select earlier studies were also included based on good methodological quality and/or the absence of more recent work. The criteria used to evaluate the interventions were based on the standardized methodology developed by the U.S. Preventive Services Task Force and the Canadian Task Force on Preventive Health Care. Twenty-one studies that met inclusion criteria were examined. These studies included interpersonal psychotherapy, cognitive-behavioral therapy, peer and partner support, nondirective counseling, relaxation/massage therapy, infant sleep interventions, infant-mother relationship therapy, and maternal exercise. Although some of these interventions have been better studied for depression unrelated to childbirth, methodological limitations render their efficacy equivocal for postpartum depression. Definite conclusions cannot be reached about the relative effectiveness of most of the nonbiological treatment approaches due to the lack of well-designed investigations. Randomized controlled trials are needed to compare different treatment modalities, examine the effectiveness of individual treatment components, and determine which treatments are most useful for women with different risk factors or clinical presentations of postpartum depression.

Treatment of postpartum depression, part 1: a critical review of biological interventions.

While postpartum depression is a major health issue for many women from diverse cultures, this affective condition often remains undiagnosed and untreated. The objective of this article is to critically review the literature to determine the current state of scientific knowledge related to the treatment of postpartum depression from a biological perspective. Databases searched for this review included MEDLINE, PubMed, CINAHL, PsycINFO, EMBASE, ProQuest, the Cochrane Library, and the WHO Reproductive Health Library from 1966 to 2003. The search terms used were postpartum/ postnatal depression and randomized controlled/ clinical trials in various combinations. Published peer-reviewed articles in English from 1990 to 2003 were chosen for review, although select earlier studies were also included based on good methodological quality and/or the absence of more recent work. The criteria used to evaluate the interventions were based on the standardized methodology developed by the U.S. Preventive Services Task Force and the Canadian Task Force on Preventive Health Care. Nine studies that met study criteria were examined. The interventions studied included antidepressant medication, estrogen therapy, critically timed sleep deprivation, and bright light therapy. Although some of these interventions have been better studied for depression unrelated to childbirth, methodological limitations render their efficacy equivocal for postpartum depression with limited strong evidence available to guide practice or policy recommendations. Despite the recent upsurge of interest in this area, many questions remain unanswered, resulting in diverse research implications. In view of the lack of randomized controlled trials, psychiatrists who are experts in the treatment of postpartum mood disorders have developed consensus guidelines. These guidelines will require regular updating as better and stronger evidence emerges.