Quality of intrapartum care for healthy women with spontaneous onset of labour in Rwanda: A health facility-based, cross-sectional study

Evidence-based intrapartum care during vaginal births: Direct observations in a tertiary care hospital in Central Sri Lanka

Background

Evidence-based practice (EBP) is an effective approach to improve maternal and newborn outcomes at birth.

Objective

This study aimed to assess the current intrapartum practices of a tertiary care hospital in Central Province, Sri Lanka, during vaginal births. The benchmark for this assessment was the World Health Organisation's (WHO) recommendations on intrapartum care for a positive childbirth experience.

Methods

An observational study was conducted at the delivery room of Teaching Hospital, Peradeniya with the participation of 196 labouring women who were selected using systematic random sampling. A non-participant observation checklist covering labour room admission procedures, management of the first, second, and third stages of labour, and immediate care of the newborn and postpartum mother was used for the data collection. The care interventions implemented throughout labour and childbirth were observed and recorded. The data analysis was done using SPSS version 22.

Results

WHO-recommended practices such as providing privacy (33.2%), offering oral fluids (39.3%), and opioids for pain relief (48.5%) were found to be infrequent. Encouraging correct pushing techniques (77.6%), early breastfeeding (83.2%), regular assessment of vaginal bleeding (91.3%), skin-to-skin contact (93.4%), and using prophylactic uterotonics (100.0%) were found to be frequent. However, labour companionship, use of upright positions during labour, women's choice of birth position, and use of manual or relaxation techniques for pain relief were not observed in hospital intrapartum care.

Conclusion

The findings of the study indicate that additional attention and monitoring are required to align the current intrapartum care practices with the WHO recommendations. Moreover, the adoption of evidence-based intrapartum care should be encouraged by conveying the standard evidence-based intrapartum care guidelines to the grassroots level healthcare workers to avoid intrapartum interventions.

Reported respectful maternity care received during childbirth at health facilities: A cross sectional survey in Eastern province, Rwanda

BACKGROUND

Respectful maternity care (RMC) fosters positive childbirth experiences and ensures safe motherhood. While past Rwandan studies on childbirth predominantly focused on negative experiences, our research delved into positive experiences. This study aimed to assess the RMC level experienced by women during childbirth in health facilities of Eastern Province of Rwanda.

METHODOLOGY

We conducted a cross-sectional survey on 610 mothers at their discharge across five public hospitals. We used a 15-items RMC questionnaire developed by White Ribbon Alliance, version of 2019. To manage the right-skewed data, we employed a median cut-off, categorizing experiences into binary outcome (low and high RMC score). We performed stepwise backward elimination logistic regression model to identify predictors of high RMC.

FINDINGS

The majority (70.2%) reported experiencing RMC. The most acclaimed RMC items (over 90%) included allowance of food and fluid intake (98.5%), non-discrimination (96.2%), receipt of necessary services (96.1%), and privacy (91.3%). The chi-square analysis showed an association between reported high RMC and marital status (p-value = 0.006), occupation (p-value = 0.001), and mode of delivery (p-value = 0.001). Caesarean section delivery was associated with high RMC in multivariate logistic regression with a p-value of 0.001, the adjusted odds ratio was 2.11 with a CI [1.40-3.17].

CONCLUSION

The reported RMC items and care appreciated at high level should be sustained. Regardless of mode of delivery, all mothers should experience consistent, utmost respect throughout the childbirth and should receive RMC at maximum level.

From global recommendations to (in)action: A scoping review of the coverage of companion of choice for women during labour and birth

Women greatly value and benefit from the presence of someone they trust to support them throughout labour and childbirth ('labour companion of choice'). Labour companionship improves maternal and perinatal outcomes, including enhancing physiological labour and birth experiences. Despite clear benefits, implementation is slow. We conducted a scoping review to assess coverage and models of labour companionship, including quantitative studies reporting coverage of labour companionship in any level health facility globally. We searched MEDLINE, CINAHL, and Global Health from 1 January 2010-14 December 2021. We extracted data on study design, labour companionship coverage, timing and type of companions allowed, and recoded data into categories for comparison across studies. We included data from a maternal health sentinel network of hospitals in Latin America, using descriptive statistics to assess coverage among 120,581 women giving birth in these sites from April 2018-April 2022. In the scoping review, we included 77 studies from 27 countries. There was wide variation in the coverage of labour companionship: almost one-third of studies reported coverage less than 40%, and one-third of studies reported coverage between 40-80%. Husbands or partners were the most frequent companion (37.7%, 29/77), followed by family member or friend (gender not specified) (32.5%, 25/77), family member or friend (female-only) (13.0%, 10/77). Across nine sentinel hospitals in five Latin American countries, there was variation in coverage, with no companion at any time ranging from 14.9%-93.8%. Despite the well-known benefits and factors affecting implementation of labour companionship, more work is needed to improve equitable coverage. Concerted efforts are needed to engage with communities, health workers, health managers, and policy-makers to establish policies, address implementation barriers, and integrate data on coverage into perinatal records and quality processes to ensure that all women have access. Harmonized reporting of labour companionship would greatly enhance understanding at global level.

Women's childbirth experience emphasizing own capacity and safety: A cross-sectional Rwandan study

PROBLEM AND AIM

Women's childbirth experience is central when assessing intrapartum care quality. This study accordingly measures women's childbirth experience in Rwandan health facilities, focusing on own capacity and perceived safety.

METHODS

A cross-sectional health facility-based study was conducted December 2014 to January 2015 in Kigali City and the Northern Province. Childbirth experience was assessed before discharge using an overall assessment and two subscales, Own capacity and Perceived safety, of the Childbirth Experience Questionnaire, with high scores reflecting a good experience. The questionnaire was translated from English into Kinyarwanda. Reliability was tested using Cronbach's alpha; and mean scores between groups were compared using Mann-Whitney U test.

FINDINGS

All invited women (n = 817) agreed to participate after informed consent. Mean age was 27.8 years and 63.6% were multiparous. A majority of women (82.3%) reported an overall positive childbirth experience (≥8 out of 10). Cronbach's alpha indicated good reliability for Own capacity (0.78) and Perceived safety (0.76). In both subscales multiparous women had higher mean scores than primiparous, married women scored higher than unmarried, older women (>35) scored higher than younger (<35), and women with higher level of education scored higher than those with lower level. Women with HIV scored lower on perceived safety.

CONCLUSION

A majority of the women reported a positive overall childbirth experience. Own capacity and perceived safety are important dimensions of childbirth experience and should be addressed in building high-quality intrapartum care. Further research is needed and should include exploration of specific groups.

Augmentation of labor with oxytocin and its association with delivery outcomes: A large-scale cohort study in 12 public hospitals in Nepal

INTRODUCTION

The use of oxytocin to augment labor is increasing in many low-resource settings; however, little is known about the effects of such use in contexts where resources for intrapartum monitoring are scarce. In this study, we sought to assess the association between augmentation of labor with oxytocin and delivery outcomes.

MATERIAL AND METHODS

We conducted a cohort study in 12 public hospitals in Nepal, including all deliveries with and without augmentation of labor with oxytocin, but excluding elective cesarean sections, women with missing information on augmentation of labor, and women without fetal heart rate on admission. Bivariate and multivariate logistic regression calculating the crude and adjusted risk ratio (aRR) with corresponding 95% CI were performed, comparing (a) intrapartum stillbirth and first-day mortality (primary outcome); and (b) intrapartum monitoring, mode of delivery, postpartum hemorrhage, bag-and-mask ventilation of the newborn, Apgar score, and neonatal death before discharge (secondary outcomes) among women with and without oxytocin-augmented labor.

RESULTS

The total cohort consisted of 78 931 women, of whom 28 915 (37%) had labor augmented with oxytocin and 50 016 (63%) did not have labor augmented with oxytocin. Women with augmentation of labor had no increased risk of intrapartum stillbirth and first-day mortality (aRR 1.24, 95% CI 0.65-2.4), but decreased risks of suboptimal partograph use (aRR 0.71, 95% CI 0.68-0.74), suboptimal fetal heart rate monitoring (aRR 0.50, 95% CI 0.48-0.53), and emergency cesarean section (aRR 0.62, 95% CI 0.59-0.66), and increased risks of bag-and-mask ventilation (aRR 2.1, 95% CI 1.8-2.5), Apgar score <7 at 5 minutes (aRR 1.65, 95% CI 1.49-1.86), and neonatal death (aRR 1.93, 95% CI 1.46-2.56).

CONCLUSIONS

Although augmentation of labor with oxytocin might be associated with beneficial effects, such as improved monitoring and a decreased risk of cesarean section, its use may lead to an increased risk of adverse perinatal outcomes. We urge for a cautious use of oxytocin to augment labor in low-resource contexts, and call for evidence-based guidelines on augmentation of labor in low-resource settings.