Task shifting in active management of the third stage of labor: a systematic review

Risk factors of primary postpartum hemorrhage among postnatal mothers in the public hospital of southern Tigray, Ethiopia, 2019: A case-control study

Background

Postpartum hemorrhage is the most common direct cause of maternal mortality and morbidity; among them, primary postpartum hemorrhages are an enormous element. Although it has an incredible impact on maternal lifestyle, this is the most neglected area in Ethiopia and there is a lack of studies achieved within the study area. So this study aimed to identify the risk factors of primary postpartum hemorrhage among postnatal mothers in public hospitals in southern Tigray, Ethiopia, 2019.

Methods

Institution-based unmatched case-control study design was conducted on 318 (106 case and 212 controls) postnatal mothers in public hospitals of Southern Tigray from January to October 2019. We used a pretested, structured interviewer-administered questionnaire and a chart review to collect the data. Bivariate and multivariable logistic regression models were used to identify the risk factors. P-value ≤ 0.05 was considered statically significant for both steps and an odds ratio with a 95% confidence level was used to see the strength of association.

Results

Abnormal third stage of labor [adjusted odds ratio = 5.86, 95% confidence interval (2.55-13.43), P = 000], cesarean section [adjusted odds ratio = 5.61, 95% confidence interval (2.79-11.30), P = 0.000], lack of active management of third-stage labor [adjusted odds ratio = 3.88; 95% confidence interval (1.29-11.60), P = 0.015], absence of labor monitoring by partograph [adjusted odds ratio = 3.82, 95% confidence interval (1.31-11.09), P = 0.014], lack of antenatal care [adjusted odds ratio = 2.76, 95% confidence interval (1.13-6.75), P = 0.026] and complications during pregnancy [adjusted odds ratio = 2.79, 95% confidence interval (1.34-5.83), P = 0.006] were found to be risk factors for primary postpartum hemorrhage.

Conclusion

In this study complications and lack of maternal health interventions in the course of the antepartum and the intrapartum period were found to be risk factors for primary postpartum hemorrhage. A strategy for improving essential maternal health services and detecting and handling complications in a timely manner will help to prevent primary postpartum hemorrhage.

A realist review of interventions targeting maternal health in low- and middle-income countries

Maternal mortality is disproportionately higher in low- and middle-income countries compared to other parts of the world. International research efforts are reflective of the urgency to improve global maternal outcomes. The existing literature of maternal health interventions in low- and middle-income countries targets a variety of populations and intervention types. However, there is a notable lack of systemic reviews that examine the wider contextual and mechanistic factors that have contributed to the outcomes produced by interventions. This article aims to use realist synthesis design to identify and examine the relationships between the contexts, mechanisms and outcomes of maternal health interventions conducted in low- and middle-income countries. This will inform evidence-based practice for future maternal health interventions. In May 2022, we searched four electronic databases for systematic reviews of maternal health interventions in low- and middle-income countries published in the last 5 years. We used open and axial coding of contexts, mechanisms and outcomes to develop an explanatory framework for intervention effectiveness. After eligibility screening and full-text analysis, 44 papers were included. The majority of effective interventions reported good healthcare system contexts, especially the importance of infrastructural capacity to implement and sustain the intervention. Most intervention designs used increasing knowledge and awareness at an individual and healthcare-provider level to produce intended outcomes. The majority of outcomes reported related to uptake of healthcare services by women. All mechanism themes had a relationship with this outcome. Health system infrastructure must be considered in interventions to ensure effective implementation and sustainability. Healthcare-seeking behaviours are embedded within social and cultural norms, environmental conditions, family influences and provider attitudes. Therefore, effective engagement with communities and families is important to create new norms surrounding pregnancy and delivery. Future research should explore community mobilization and involvement to enable tailored interventions with optimal contextual fit.

Current state and future direction of task shifting in obstetric and gynecological care: A survey of obstetrician-gynecologists across Japan

To conduct a survey about task shifting in obstetric and gynecological care.A multivariate logistic regression analysis was conducted in Japanese hospitals using obstetrician-gynecologists (OB/GYNs) who answered that task shifting was rarely used at their working environment as the outcome variable and using their personal attributes (sex, age, type of medical institution employed at, and regional characteristics) as predictor variables. Opinions were gathered regarding promoting task shifting impact on individual work duties.Responses were collected from 919 OB/GYNs (49.9% women, 50.8% <40 years). Characteristics' analysis of 34.6% of OB/GYNs who thought that task shifting was hardly used indicated that it was used significantly more at private university hospitals (odds ratio 5.33, 95% confidence interval: 2.33-12.18) than at national university hospitals (odds ratio 3.54, 95% confidence interval: 1.67-7.51). "Transfer of patients (from operating rooms to the ward)" and "securing the contrast agent line" were the only items related to the task shifting status for individual work duties that were identified by most respondents, revealing that task shifting is not progressing. More than half and 9% of the OB/GYNs said that task shifting progression would improve and decline medical care quality, respectively. Overall, 46% and 24% of the respondents thought that task shifting could reduce working hours by ">1 hour, but <2 hours"/day and "<1 hour"/day, respectively.The current study confirmed that OB/GYNs working at university hospitals believe that task shifting is not progressing in university hospitals and that the working environment is poor. Even if task shifting reduces the number of working hours per day by 2 hours, the working hours of these physicians still exceed the criteria for death by overwork. Thus, further working hour reduction measures are needed in addition to task shifting, such as consolidation of medical institutions dealing with deliveries.To promote task shifting in obstetrical and gynecological care in Japan, it is necessary to continue promoting policy-based, institutional, and educational guidance.

Healthcare providers experiences of using uterine balloon tamponade (UBT) devices for the treatment of post-partum haemorrhage: A meta-synthesis of qualitative studies

BACKGROUND

Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and severe morbidity globally. When PPH cannot be controlled using standard medical treatments, uterine balloon tamponade (UBT) may be used to arrest bleeding. While UBT is used by healthcare providers in hospital settings internationally, their views and experiences have not been systematically explored. The aim of this review is to identify, appraise and synthesize available evidence about the views and experiences of healthcare providers using UBT to treat PPH.

METHODS

Using a pre-determined search strategy, we searched MEDLINE, CINAHL, PsycINFO, EMBASE, LILACS, AJOL, and reference lists of eligible studies published 1996-2019, reporting qualitative data on the views and experiences of health professionals using UBT to treat PPH. Author findings were extracted and synthesised using techniques derived from thematic synthesis and confidence in the findings was assessed using GRADE-CERQual.

RESULTS

Out of 89 studies we identified 5 that met our inclusion criteria. The studies were conducted in five low- and middle-income countries (LMICs) in Africa and reported on the use of simple UBT devices for the treatment of PPH. A variety of cadres (including midwives, medical officers and clinical officers) had experience with using UBTs and found them to be effective, convenient, easy to assemble and relatively inexpensive. Providers also suggested regular, hands-on training was necessary to maintain skills and highlighted the importance of community engagement in successful implementation.

CONCLUSIONS

Providers felt that administration of a simple UBT device offered a practical and cost-effective approach to the treatment of uncontrolled PPH, especially in contexts where uterotonics were ineffective or unavailable or where access to surgery was not possible. The findings are limited by the relatively small number of studies contributing to the review and further research in other contexts is required to address wider acceptability and feasibility issues.

Knowledge and barriers on correct use of modified guidelines for active management of third stage of labour: a cross sectional survey of nurse-midwives at three referral hospitals in Dar es Salaam, Tanzania

Background

Despite the fact that it is possibly preventable, postpartum haemorrhage (PPH) is the global most deadly form of obstetric bleeding, mainly sub-Saharan Africa with at least one-fourth of maternal deaths in East African regions. Active management of third stage of labour (AMTSL) is recommended to prevent PPH. However, AMTSL guidelines have been revised since 2006.

Objectives

To examine the current status of nurse-midwives' knowledge on modified AMTSL guidelines and highlight barriers to AMTSL correct use.

Method

Descriptive cross sectional survey was conducted to 160 nurse-midwives at three referral hospitals in Dar es Salaam, Tanzania. One-way, interactive modes ANOVA and Chi square (χ2) test were run in SPSS 21 version to compare the association of independent and dependent variables.

Results

Virtually all nurse-midwives knew the first recommended uterotonic (99.4%) and delayed cord clamping (98.8%) protocols as modified. Knowledge was significantly contributed by multiple factors; p=0.001. Reported correct AMTSL use was 46.8% which was significantly affected by AMTSL training (χ2 = 6.732, p = 0.009) and prioritizing atteding an asphyxiated baby (χ2 = 5.647, p = 0.017).

Conclusion

Regardless of high nurse-midwives' AMTSL knowledge; it is imperative that responsible authorities plan appropriate strategies to solve reported barriers affecting correct AMTSL use.

How can task shifting put patient safety at risk? A qualitative study of experiences among general practitioners in Norway

Objective: To describe experiences among general practitioners (GPs) in Norway regarding horizontal task shifting experiences associated with adverse events that potentially put patient safety at risk.Design and contributors: We conducted a qualitative study with data from a retrospective convenience sample of consecutive, already posted comments in a restricted Facebook group for GPs in Norway. The sample consisted of 43 unique posts from 38 contributors (23 women and 15 men), presenting thick and specific accounts of potentially adverse events in the context of horizontal task shifting. Analysis was conducted with systematic text condensation, a method for thematic cross-case analysis.Results: Contributing GPs reported several types of adverse events associated with horizontal task shifting that could put patient safety at risk. They described how spill-over work dispatched to GPs may generate administrative hassle and hazardous delay of necessary examinations. Overdiagnosis, reduced access and endangered accountability occur when time-consuming procedures and pre-investigation before referral are pushed upon GPs. Resource-draining chores beyond GPs' proficiency is also dispatched without appropriate instruction or equipment. Furthermore, potential malpractice is imposed by hospital colleagues who overrule the GPs' medical judgement.Implications: Patient safety is endangered when horizontal task shifting is initiated and performed without a systematic process involving all stakeholders that considers available resources. A risk and vulnerability analysis, securing competent staff, resources, time and equipment before launching such reforms is necessary to protect patient safety. Infrastructure comprised of local coordination groups may facilitate dialogue between health care service levels and negotiate responsibilities and workload.Key pointsTask shifting between different levels of health care is a relevant and legitimate strategy for planning and policy.GPs in Norway report adverse events related to task shifting from specialist colleagues without proper resource allocation.Patient safety may be put at risk by hazardous delay, overdiagnosis, endangered accountability and potential malpractice.Planning and implementation of task shifting must involve all system levels and relevant stakeholders to ensure patient safety.

Vital Signs Directed Therapy for the Critically Ill: Improved Adherence to the Treatment Protocol Two Years after Implementation in an Intensive Care Unit in Tanzania

Treating deranged vital signs is a mainstay of critical care throughout the world. In an ICU in a university hospital in Tanzania, the implementation of the Vital Signs Directed Therapy Protocol in 2014 led to an increase in acute treatments for deranged vital signs. The mortality rate for hypotensive patients decreased from 92% to 69%. In this study, the aim was to investigate the sustainability of the implementation two years later. An observational, patient-record-based study was conducted in the ICU in August 2016. Data on deranged vital signs and acute treatments were extracted from the patients' charts. Adherence to the protocol, defined as an acute treatment in the same or subsequent hour following a deranged vital sign, was calculated and compared with before and immediately after implementation. Two-hundred and eighty-nine deranged vital signs were included. Adherence was 29.8% two years after implementation, compared with 16.6% (p < 0.001) immediately after implementation and 2.9% (p < 0.001) before implementation. Consequently, the implementation of the Vital Signs Directed Therapy Protocol appears to have led to a sustainable increase in the treatment of deranged vital signs. The protocol may have potential to improve patient safety in other settings where critically ill patients are managed.

"My job is to get pregnant women to the hospital": a qualitative study of the role of traditional birth attendants in the distribution of misoprostol to prevent post-partum haemorrhage in two provinces in Mozambique

Background

Post-partum haemorrhage is the leading cause of maternal deaths in Mozambique. In 2015, the Mozambican Ministry of Health launched the National Strategy for the Prevention of Post-Partum Haemorrhage at the Community Level. The strategy included the distribution of misoprostol to women in advance at antenatal care and via Traditional Birth Attendants who directly administer the medication. The study explores the role of Traditional Birth Attendants in the misoprostol program and the views of women who used misoprostol to prevent post-partum haemorrhage.

Methods

This descriptive study collected data through in-depth interviews and focus group discussions. Traditional Birth Attendants between the ages of 30–70 and women of reproductive age participated in the study. Data was collected between June–October 2017 in Inhambane and Nampula Provinces. Line by line thematic analysis was used to interpret the data using Nvivo (v.11).

Results

The majority of TBAs in the study were satisfied with their role in the misoprostol program and were motivated to work with the formal health system to encourage women to access facility based births. Women who used misoprostol were also satisfied with the medication and encouraged family and friends to access it when needed. Women in the community and Traditional Birth Attendants requested assistance with transportation to reach the health facility to avoid home births.

Conclusions

This study contributes to the evidence base that Traditional Birth Attendants are an appropriate channel for the distribution of misoprostol for the prevention of post-partum haemorrhage at the community level. More support and resources are needed to ensure Traditional Birth Attendants can assist women to have safe births when they are unable to reach the health facility. A consistent supply of misoprostol is needed to ensure women at the community level receive this life saving medication.