Intrapartum fetal deaths and unexpected neonatal deaths in the Republic of Ireland: 2011 - 2014; a descriptive study

Potential prevention of stillbirth caused by placental abruption: a regional population-based study in Japan

OBJECTIVE

Placental abruption is associated with adverse perinatal outcomes including intrauterine fetal demise, which subsequently results in stillbirth. However, few studies have demonstrated the preventability of stillbirth due to placental abruption. Therefore, we evaluated the possibility of preventing stillbirth caused by placental abruption by reviewing all stillbirths in our region.

METHODS

This study reviewed all stillbirths after 22 weeks of gestation in Shiga Prefecture, Japan from 2010 to 2019, excluding lethal disorders. We evaluated 350 stillbirth cases, with and without placental abruption.

RESULTS

There were 32 stillbirths with PA and 318 without placental abruption. The probability of preventing stillbirth was significantly higher in patients with placental abruption than in those without (30% vs. 8%, p < 0.001). We also determined the recommendations for preventing stillbirths with placental abruption.

CONCLUSION

Some stillbirths caused by placental abruption can be prevented. We recommend improvements to perinatal maternal-fetal care and perinatal emergency transport systems.

Experiences of community health workers on adopting mHealth in rural Malawi: A qualitative study

Background

The use of mobile health technology (mHealth) by community health workers (CHWs) can strengthen community-based service delivery and improve access to and quality of healthcare.

Objective

This qualitative study sought to explore experiences and identify factors influencing the use of an integrated smartphone-based mHealth called YendaNafe by CHWs in rural Malawi.

Methods

Using pre-tested interview guides, between August and October 2022, we conducted eight focus group discussions with CHWs (n = 69), four in-depth interviews with CHW supervisors, and eight key informant interviews in Neno District, Malawi. We audio-recorded and transcribed the interviews verbatim and organized them for analysis in Dedoose V9.0.62. We used an inductive analysis technique to analyze the data. We further applied the six domains of the socio-technical system (STS) framework to map factors influencing the use of YendaNafe.

Results

User experiences and facilitators and barriers were the two main themes that emerged. mHealth was reported to improve the task efficiency, competence, trust, and perceived professionalism of CHWs. CHWs less frequently referred to cultural factors influencing app uptake. However, for other social systems, they identified relationships and trust with stakeholders, availability of training and programmatic support, and performance monitoring and feedback as influencing the use of YendaNafe. From the STS technical domain, the availability and adequacy of hardware such as phones, mobile connectivity, and usability influenced the use of YendaNafe.

Conclusions

Despite the initial discomfort, CHWs found mHealth helpful in supporting their service delivery tasks. Identifying and addressing social and technical factors during mHealth implementation may help improve end users' attitudes and uptake.

Modeling clinical and non-clinical determinants of intrapartum stillbirths in singletons in six public hospitals in the Greater Accra Region of Ghana: a case-control study

The Greater Accra Region (GAR) of Ghana records 2000 stillbirths annually and 40% of them occur intrapartum. An understanding of the contributing factors will facilitate the development of preventive strategies to reduce the huge numbers of intrapartum stillbirths. This study identified determinants of intrapartum stillbirths in GAR. A retrospective 1:2 unmatched case-control study was conducted in six public hospitals in the Greater Accra Region of Ghana. A multivariable binary logistic regression model was used to quantify the effect of exposures on intrapartum stillbirth. The area under the receiver operating characteristics curve and the Brier scores were used to screen potential risk factors and assess the predictive performance of the regression models. The following maternal factors increased the odds of intrapartum stillbirths: pregnancy-induced hypertension (PIH) [adjusted Odds Ratio; aOR = 3.72, 95% CI:1.71-8.10, p < 0.001]; antepartum haemorrhage (APH) [aOR = 3.28, 95% CI: 1.33-8.10, p < 0.05] and premature rupture of membranes (PROM) [aOR = 3.36, 95% CI: 1.20-9.40, p < 0.05]. Improved management of PIH, APH, PROM, and preterm delivery will reduce intrapartum stillbirth. Hospitals should improve on the quality of monitoring women during labor. Auditing of intrapartum stillbirths should be mandatory for all hospitals and Ghana Health Service should include fetal autopsy in stillbirth auditing to identify other causes of fetal deaths. Interventions to reduce intrapartum stillbirth must combine maternal, fetal and service delivery factors to make them effective.

Disruptions to healthcare quality and early child health outcomes: Evidence from health-worker strikes in Kenya

This paper measures the effects of disruptions to healthcare quality at birth on early child health outcomes in Kenya. To identify impacts, we exploit variation in the timing and location of health-worker strikes at individual hospitals across the country between 1999 and 2014. Using data from Demographic Health Surveys, we find that children born during strikes are more likely to suffer a neonatal death. We find similar results using separate data collected in two informal settlements in Nairobi located near hospitals with frequent strikes. These results show that interruptions to healthcare quality can have large immediate health impacts, and suggests that status quo hospital care provides positive benefits. We also find suggestive evidence of reductions in later health investments, measured by vaccine take-up, among those who survive. This study provides the first rigorous evidence on the consequences of health-worker strikes, a frequent but understudied phenomenon in Sub-Saharan Africa.

Perinatal mortality audits and reporting of perinatal deaths: systematic review of outcomes and barriers

BACKGROUND

Perinatal deaths are a devastating experience for all families and healthcare professionals involved. Audit of perinatal mortality (PNM) is essential to better understand the factors associated with perinatal death, to identify key deficiencies in healthcare provision and should be utilised to improve the quality of perinatal care. However, barriers exist to successful audit implementation and few countries have implemented national perinatal audit programs.

CONTENT

We searched the PubMed, EMBASE and EBSCO host, including Medline, Academic Search Complete and CINAHL Plus databases for articles that were published from 1st January 2000. Articles evaluating perinatal mortality audits or audit implementation, identifying risk or care factors of perinatal mortality through audits, in middle and/or high-income countries were considered for inclusion in this review. Twenty articles met inclusion criteria. Incomplete datasets, nonstandard audit methods and classifications, and inadequate staff training were highlighted as barriers to PNM reporting and audit implementation. Failure in timely detection and management of antenatal maternal and fetal conditions and late presentation or failure to escalate care were the most common substandard care factors identified through audit. Overall, recommendations for perinatal audit focused on standardised audit tools and training of staff. Overall, the implementation of audit recommendations remains unclear.

SUMMARY

This review highlights barriers to audit practices and emphasises the need for adequately trained staff to participate in regular audit that is standardised and thorough. To achieve the goal of reducing PNM, it is crucial that the audit cycle is completed with continuous re-evaluation of recommended changes.

Trends of changes in the specific contribution of selected risk factors for shoulder dystocia over a period of more than two decades

Objectives Shoulder dystocia (SD) is an obstetrical emergency with well-recognized risk factors. We aimed to identify trends of changes in the specific contribution of risk factors for SD over time. Methods A nested case control study comparing all singleton deliveries with and without SD was undertaken. A multivariable logistic regression model was used in order to identify independent risk factors for SD and a comparison of the prevalence and the specific contribution (odds ratio (OR)) of the chosen risk factors in three consecutive eight-year intervals from 1988 to 2014 was performed. Results During the study period, there were 295,946 deliveries. Of them 514 (0.174%) were complicated with SD. Between 1988 and 2014 the incidence of SD has decreased from 0.3% in 1988 to 0.1% in 2014. Using a logistic regression model grandmultiparity, diabetes mellitus (DM), fetal weight, and large for gestational age (LGA) were found to be independent risk factors for SD (OR 1.25 95% CI 1.04-1.51, p=0.02; OR 1.53 95% CI 1.19-1.97, p=0.001; OR 1.002 95% CI 1.001-1.002, p < 0.001; OR 3.88 95% CI 3.09-4.87, p < 0.001; respectively). While the OR for grandmultiparity, fetal weight, and LGA has significantly changed during the study period with a mixed trend, the OR of DM has demonstrated a significant linear increase over time. Conclusions The individual contribution of selected risk factors for the occurrence of SD has significantly changed throughout the years. The contribution of DM has demonstrated a linear increase over time, emphasizing the great impact of DM on SD.

Perinatal mortality audits and reviews: Past, present and the way forward

Perinatal deaths are devastating for families and staff involved. Failure to examine perinatal deaths for substandard care prevents learning and may lead to recurrence of events, as well as prolonged morbidity in bereaved families and hospital staff. Perinatal mortality reviews can identify factors contributing to suboptimal care. An integrative literature review was carried out to study the different types of perinatal mortality reviews currently being done internationally, establishing a comparison and examining promising new developments. We start by outlining issues with the classification of perinatal deaths and the different types of perinatal mortality reviews carried out in high-income countries. We reflect on the challenges that are encountered in the current processes and we then comment on how these may be overcome. Current literature shows that differences in classifications of perinatal deaths continue to impede important international comparisons. National perinatal mortality audits can provide reliable high-quality data to facilitate national and international benchmarking. Confidential enquiries give expert assessment on anonymised information to initiate system-wide improvements, but to provide local information on perinatal deaths unit-based multi-disciplinary team reviews are required. Additionally, there is a need to shift from a blame-culture to a focus on achieving best practice by learning from mistakes. Review tools and processes have been implemented in some countries to standardize perinatal mortality reviews, but there is still more work to be done. Involving the bereaved parents in the perinatal mortality review process is important and ways to achieve this are progressing. A structured approach to the perinatal mortality review process should be developed to facilitate sharing of experiences and challenges at national (or international) level. To achieve a reduction in the number of stillbirths and neonatal deaths, it is crucial to ensure that the perinatal mortality audit and review cycle is completed with implementation and re-evaluation of recommended changes in maternity services.

Impact of consultant obstetric presence on serious incidents

Purpose

Many organisations, including the Royal College of Obstetricians and Gynaecologists, have recommended increasing the number of hours of consultant obstetric presence in UK National Health Service maternity units to improve patient care. St Mary’s Hospital, Manchester implemented 24-7 consultant presence in September 2014. The paper aims to discuss these issues.

Design/methodology/approach

To assess the impact of 24-7 consultant presence upon women and babies, a retrospective review of all serious clinical intrapartum incidents occurring between September 2011 and September 2017 was carried out by two independent reviewers; disagreements in classification were reviewed by a senior Obstetrician. The impact of consultant presence was classified in a structure agreed a priori.

Findings

A total of 72 incidents were reviewed. Consultants were directly involved in the care of 75.6 per cent of cases before 24-7 consultant presence compared to 96.8 per cent afterwards. Negative impact due to a lack of consultant presence fell from 22 per cent of the incidents before 24-7 consultant presence to 9.7 per cent after implementation. In contrast, positive impact of consultant presence increased from 14.6 to 32.3 per cent following the introduction of 24-7 consultant presence.

Practical implications

Introduction of 24-7 consultant presence reduced the negative impact caused by a lack of, or delay in, consultant presence as identified by serious untoward incident (SUI) reviews. Consultant presence was more likely to have a positive influence on care delivery.

Originality/value

This is the first assessment of the impact of 24-7 consultant presence on the SUIs in obstetrics.

The perceived effect of serious adverse perinatal events on clinical practice. Can it be objectively measured?

OBJECTIVE

Obstetrics involves a high degree of clinical risk. While serious adverse events resulting in substantial maternal or neonatal morbidity or mortality are relatively rare it has been shown that exposure to a such an event can have a predominantly negative personal and professional impact on the healthcare professionals who are involved. There is little in the published literature to show an objective change in clinical practice as a result of an adverse event. The aim of this study was to identify if it was feasible to design a study that could objectively demonstrate if a change in labour ward clinical activity occurred in the 28 days following a serious adverse perinatal event. If this proved possible, the second aim was to identify if these changes could be attributed to the preceding adverse event.

STUDY DESIGN

This study was conducted in a large tertiary teaching hospital in Ireland. This was a retrospective observational study conducted using data from a 25-month period from August 2013 to September 2015. Six of the most serious adverse perinatal events that occurred over that time period were identified from the hospital's clinical risk register. Various outcome variables in the form of aggregate data on all deliveries that occurred in CUMH for the 28 days preceding and succeeding the events were collected by the lead author. The medical records for each severe adverse perinatal event were reviewed and the clinical case details recorded. Based on these clinical details individual hypotheses were created for each event. Data was analysed using IBM-SPSS.

RESULTS

Aggregate data relating to 6180 deliveries was collected and analysed. Data analysis revealed some statistically significant changes in clinical activity in the 28 days following five of the six adverse events. These changes in clinical activity did not, however, always match what we had expected from our original hypotheses.

CONCLUSION

This novel study aimed to identify if it was possible to objectively demonstrate this practice change. We identified some statistically significant changes in clinical activity in the 28 days following five of the six adverse events but were unable to definitively conclude if the change in activity was a direct result of each event.

The implications of high carbon monoxide levels in early pregnancy for neonatal outcomes

OBJECTIVES

The aim of this study was to examine the implications of increased maternal Breath Carbon Monoxide (BCO) levels at the first antenatal visit for subsequent birthweight (BW) and neonatal outcomes.

STUDY DESIGN

Secondary analysis of a prospective, observational study. Pregnant women aged ≥18years who understood English were recruited (n=250). However, only women who delivered a normally formed baby weighing ≥500g were analysed (n=234). At the first antenatal visit, a research questionnaire was completed and a BCO test was performed. Obstetric and neonatal data computerised by midwives at the first antenatal visit and updated after delivery were also analysed.

RESULTS

Results from the receiver operating characteristic (ROC) curve indicated the highest combined sensitivity and specificity for smoking was observed at a BCO cut-off level of 3ppm (sensitivity 85%, specificity 90%). Of the 234 women, 53 (22.6%) had a BCO ≥3ppm but only 36 (15.4%) disclosed smoking to the midwife on routine questioning. A further 23 (9.8%) were classified as non-disclosers based on a research questionnaire and/or a BCO measurement ≥3ppm. No relationship was found between the self-reported number of cigarettes daily in early pregnancy and BW (r=0.05, p=0.78). However, an inverse relationship was found between maternal BCO levels and BW (r=-0.31, p<0.001). BCO levels ≥3ppm in early pregnancy were associated with an increased risk of emergency caesarean section, low birth weight, BW <25th centile, fetal distress and having two or more adverse pregnancy events (all p<0.05). Smoking non-disclosers had babies with decreased BWs (-400.1g, 95% CI 141.1-659.0g, p<0.001), and higher rates of BW <25th centile (56.5% versus 25.3%, p<0.001), small-for-gestational-age (21.7% versus 9.1%, p<0.001) and fetal distress (39.1% versus 16.0%, p<0.01) compared to non-smokers Non-disclosers at the first antenatal visit also had a 22% higher rate of having two or more adverse pregnancy events (p<0.05).

CONCLUSION

The results showed that an increased BCO level was associated with a lower BW and increased risk of adverse pregnancy and neonatal outcomes. This strengthens the case for universal BCO screening at the first antenatal visit. A high BCO reading should be an indication for referral to stop smoking services referral and close fetal surveillance.