Surgical complications after caesarean section: A population-based cohort study

Factors associated with quality of intrapartum care in Kenya: a complex samples analysis of the 2022 Kenya demographic and health survey

BACKGROUND

The provision of quality intrapartum care increases women's utilization of skilled birth attendants in health facilities and improves maternal and newborn health. This study aimed to investigate the factors associated with the quality of intrapartum care using the 2022 Kenya Demographic and Health Survey (KDHS).

METHODS

Secondary data from the 2022 KDHS of 11,863 participants, who were selected by multistage stratified sampling, was used. Based on literature and the availability of indicators within the 2022 KDHS, the quality of intrapartum care was operationalized as receiving all the three clinical components of intrapartum care including a mother having a facility-based delivery, receiving skilled assistance during childbirth, and placing the newborn on the mother's breast within one hour from birth by the skilled birth attendant. Univariate and multivariate logistic regression analyses were used to analyze the data using SPSS (version 20).

RESULTS

Of the 11,863 women who had recently given birth, about 52.6% had received quality intrapartum care. As part of the intrapartum care, 88.2% gave birth in a health facility, 90.4% obtained assistance from skilled birth attendants, and 59.8% had their babies placed on the breast by a birth attendant within 1 h after birth. Women who had attained secondary education (aOR = 1.46, 95% CI: 1.23-1.90), were working (aOR 1.24, 95% CI: 1.00-1.53), had 3-4 living children (aOR = 1.31, 95% CI: 1.02-1.68), took 31-60 min to reach the health facility (aOR = 1.49, 95% CI: 1.41-1.95), were assisted during childbirth by doctors (aOR = 19.86, 95% CI: 2.89-136.43) and nurses/midwives/clinical officers (aOR = 23.09, 95% CI: 3.36-158.89) had higher odds of receiving quality intrapartum care compared with their counterparts. On the other hand, women in the richest wealth index (aOR = 0.64, 95% CI: 0.42-0.98), those who gave birth through cesarean section (AOR = 0.27, 95% CI: 0.20-0.36) and those whose current age of their child was ≥ 2years (AOR = 0.76, 95% CI: 0.60-0.96) were less likely to receive quality intrapartum care compared with their counterparts.

CONCLUSIONS

About half of the women received quality intrapartum care in Kenya, with demographic characteristics seeming to be the main drivers of quality intrapartum care. Although the Kenyan government abolished maternity services fees in all public facilities, there is still a need to empower women through increasing access to education and economic development initiatives for their economic independence. This will enable mothers to pay transport fares to health facilities for those in hard-to-reach rural settings and buy other hospital delivery requirements (e.g., surgical gloves) that may not be available in rural public health facilities, thus increasing access to skilled birth attendance and quality intrapartum care as a whole. Its also worth noting, since Kenya is moving towards provision of quality intrapartum care, more and proper indicators of clinical intrapartum care need to be captured in future DHS studies. This will enable comprehensive assessment of the quality of intrapartum in view of informing maternal health care policy in Kenya and other countries.

Multilevel analysis of quality of intrapartum care and its associated factors: evidence from 35 Sub-Saharan African countries demographic and health survey

BACKGROUND

The majority of feto-maternal morbidities and mortalities in sub-Saharan Africa, happen during the intrapartum period. Maternal mortality and morbidity have not decreased as much as anticipated, despite the significant progress made by many nations to improve access to maternity services. There are currently no nationally representative studies in sub-Saharan Africa assessing the quality of intrapartum care and its associated factors. Hence, this study aimed to determine the quality of intrapartum care and identify its associated factors using Demographic and Health Survey data from 35 countries.

METHODS

Data from the most recent health and demographic surveys, which were carried out between 2006 and 2022 in 35 sub-Saharan African countries, were used. This analysis included a weighted sample of 353,483 women who had given birth within the last five years. STATA/SE version 14.0 statistical software was used to clean, recode, and analyze data that had been taken from DHS data sets. Utilizing multilevel mixed-effects logistic regression, the factors associated with the outcome variable were identified. Model comparison and fitness were assessed using deviance (-2LLR), likelihood ratio tests, median odds ratios, and intra-class correlation coefficient values. Ultimately, factors were deemed statistically significant if they had a p-value < 0.05.

RESULTS

About 28.58% (95% CI: 28.43-28.73) of the study subjects had received quality intrapartum care. Factors the like respondent's age [AOR = 1.49; 95% CI (1.42, 1.57)], educational status [AOR = 1.80; 95% CI (1.76, 1.85)], working status [AOR = 1.03; 95% CI (1.01, 1.05)], media exposure [AOR = 1.19; 95% CI (1.16, 1.21)], household wealth index [AOR = 1.53; 95% CI (1.49, 1.56)], family size [AOR = 0.90; 95% CI (0.88, 0.92)], healthcare decisions [AOR = 1.04; 95% CI (1.01, 1.06)], sex of the household head [AOR = 1.08; 95% CI (1.05, 1.10)], ANC visits attended during pregnancy [AOR = 0.60; 95% CI (0.59, 0.61)], number of children ever born [AOR = 0.57; 95% CI (0.55, 0.58)], age at first birth [AOR = 1.06; 95% CI (1.04, 1.08)], mode of delivery [AOR = 0.71; 95% CI (0.68, 0.73)], and residence [AOR = 1.09; 95% CI (1.06, 1.11)] were significantly associated with the quality of intrapartum care.

CONCLUSIONS

In the present study, less than one in three mothers had received quality intrapartum care. Respondent's age, educational status, working status, media exposure, household wealth index, healthcare decisions, sex of the household head, age at first birth, and residence were associated with the quality of intrapartum care. Health policy makers and program planners should empower women through comprehensive education and mass media campaigns in order to maximize the quality of intrapartum care. It is also advised that each country's Ministry of Health assess its community health professionals and medical facilities in order to boost funding for rural inhabitants and lower-class households.

Rate of cesarean section among breech deliveries in Ethiopia: a systematic review and meta-analysis

Background

Breech deliveries are a significant public health concern in developing countries. The World Health Organization (WHO) declared that the cesarean section rate should not be higher than 10%-15%. As unnecessary C-sections may be associated with an increased risk of maternal and neonatal mortality, this meta-analysis was aimed at determining the rate of caesarean sections among breech deliveries in Ethiopia.

Methods

All published and unpublished articles were obtained from legitimate databases and websites. The PRISMA guidelines were used to conduct this systematic review and meta-analysis. The meta-analysis of the primary and secondary outcomes was performed using STATA version 18. The overall effect size with a 95% CI was estimated using the random effect model with the Der Simonian Liard method. A sensitivity analysis using a leave-one-out meta-analysis was computed.

Results

This meta-analysis included a total of 57,236 mothers who had breech deliveries. The pooled prevalence of breech deliveries among women in Ethiopia was 5% [95% CI: 4, 6]. The overall pooled cesarean section rate among breech deliveries in Ethiopia was 41% (95% CI: 29-54).

Conclusions

In this review, the pooled prevalence of breech deliveries among women in Ethiopia was 5%, and the overall rate of caesarian section among the breech deliveries was 41%. This finding pointed out that two out of every five pregnant women with breech presentation gave birth by cesarean section in Ethiopia. Therefore, the finding implies that both the government and all the concerned stakeholders shall be given particular emphasis made on strengthening antenatal care services and ensure more women have access to skilled healthcare professionals during childbirth. This can help in providing appropriate interventions, support to women and reducing the need for emergency and unnecessary breech deliveries. The result of this research are a baseline data for future researchers to conduct further studies to better understand the reasons behind the high rates and identify potential interventions and solutions specific to the African context.

Effects of factors influencing cesarean section rates between 2008 and 2018 in Taiwan: A population-based cross-sectional study

Many factors can affect delivery mode decisions. Therefore, this study aimed to explore the effects of maternal age, physician's sex, region, income, and hospital type on cesarean section (C/S) delivery rates between 2008 and 2018 in Taiwan. In this population-based cross-sectional study, data were extracted from the Taiwan National Health Insurance Research Database (2 million individuals). The logistic regression method was used to analyze the aforementioned risk factors, and data are expressed as odds ratios (ORs) and 95% confidence intervals. In total, 9826 and 9714 deliveries in 2008 and 2018, respectively, were included in the analysis. The C/S ratio increased from 16.5% (n = 1607) in 2008 to 19.7% (n = 1916) in 2018. A higher C/S risk for women aged >34 years (ORs: 2.835 and 2.225 in 2008 and 2018, respectively) than for those aged ≤34 years was noted in both years. Female physicians had a lower risk of performing C/S than male physicians in 2008 (OR: .762, 95% confidence interval: .625-.928), but this was not apparent in 2018. Higher income levels (>new Taiwan dollar 45,081) and central Taiwan were associated with a lower C/S risk in both years. Private, not-for-profit hospitals had a lower C/S risk in 2008, which was not apparent in 2018. In conclusion, this study revealed a significant increase in C/S rates over the past decade, which was influenced by multiple factors. Maternal age, physician's sex, income status, location, and type of hospital may influence C/S rates. Analyzing these relationships can inform the development of strategies aimed at reducing future C/S rates, and targeted interventions may reduce the C/S rates.

Burden of Medical Costs Associated with Severe Maternal Morbidity in South Korea

BACKGROUND

Adverse maternal health outcomes lead to health loss and unnecessary medical costs. However, few have explored how severe maternal morbidity (SMM) affects medical costs separately from blood transfusion. Therefore, the aim of this study was to evaluate the delivery-related costs of healthcare services in patients with and without SMM as well as blood transfusion.

METHODS

This retrospective cohort study used the National Health Insurance Service (NHIS) Delivery Cohort database in South Korea. We included all delivering mothers in South Korea from 2016 to 2021, except those with incomplete data, totaling 1,517,773 participants. The measured outcomes included delivery-related medical costs associated with SMM. A generalized estimating equation model with a log link, gamma distribution, and robust standard errors was used to estimate the mean delivery-related medical costs of SMM.

RESULTS

SMM occurred in 2.2% of the cohort. The adjusted mean delivery-related medical costs were approximately 2.1- and 1.4-fold higher in cases with SMM without blood transfusion and only blood transfusion than in those without SMM, respectively ($2005, 95% CI: $1934-2078 and $1339, 95% CI: 1325-1354, respectively). The adjusted mean delivery-related medical costs were 1.5-fold higher in cases with SMM with blood transfusion than in those without SMM (SMM $1539, 95% CI: $1513-$1565).

CONCLUSIONS

Medical costs associated with delivery-related SMM with or without blood transfusion were significantly higher than those of normal deliveries, with excess costs varying according to existing healthcare policies. Policymakers should consider supporting programs to prevent high medical costs by improving maternal health.

Current predictors for morbidity regarding choice of birth after a previous caesarean section, show poor predictive value in prediction modelling

INTRODUCTION

After a previous caesarean section, morbidity in the subsequent delivery in general is considered to depend on the probability of a vaginal birth after caesarean. However counselling could be improved by adding individualized probability of serious morbidity following either trial of labour or elective repeat caesarean section. The objective of this study was to develop prediction models for morbidity for both a repeat caesarean section and a trial of labor for a Dutch population.

MATERIAL AND METHODS

In this cohort study, data were joined from three previous studies (SIMPLE 1, SIMPLE 2 and SIMPLE 2-implementation study). A cohort of 2592 women with one previous caesarean section and a singleton pregnancy who delivered ≥37 weeks, without a contraindication for vaginal delivery was formed. Maternal morbidity was defined as postpartum hemorrhage, blood transfusion, uterine rupture, ICU admittance or death. Neonatal morbidity was defined as asphyxia, NICU-admittance or death. Potential predictors for morbidity were chosen based on literature and expert opinion. Logistic regression was used to develop the models. Internal validation was intended using bootstrapping techniques. Main outcome measures were predictors for morbidity and for validation of the model we used the area under the receiver operating characteristic curve for discriminative capacity and calibration for accuracy.

RESULTS

In 324 out of the 2592 cases (12.7 %) maternal or fetal complications occurred. In general total morbidity was higher in women choosing TOL as compared to ERCS (p < 0.001). The performance of the several developed models was insufficient, the area under the receiver operating characteristic curve did not rise above 0.6. Due to poor model performance, before correction for overfitting, interval validation was not conducted.

CONCLUSION

In this large cohort, developing a Dutch population based prediction model that aimed to improve counselling on the mode of delivery, by predicting individual chances of morbidity for different delivery modes was not possible, due to lack of performance. Further study could be directed to cut off on VBAC success rates to a more general advice regarding the safest mode of delivery.

Re-exploration following caesarean birth: a prospective national case-control study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system

BACKGROUND

Re-exploration following caesarean birth and the associated maternal morbidity has not been investigated in the UK. Our aims were to determine the national incidence and identify the associated risk factors.

METHODS

We conducted a prospective observational case-control study across 194 UK consultant-led maternity units in women whose caesarean birth was complicated by a re-exploration. Independent factors for re-exploration were analysed using multivariable multi-level mixed effects logistic regression.

RESULTS

Over the study period (1 June 2021 and 31 May 2022) 238,423 caesarean births were recorded across the UK of which 187 women underwent re-exploration, giving an incidence of one re-exploration per 1282 caesarean births (95%CI 1:1099-1:1471). Haemorrhage (124/187, 66.3%) and sepsis (31/187, 16.6%) were the most common findings at re-exploration. Median (IQR [range]) time interval to re-exploration following the caesarean birth was 1 (0-4 [0-28]) day. Mechanical ventilation was required in 34 (18.6%) women, cardiac arrest was reported in 5 (2.7%) and 3 (1.6%) women died. Independent preceding factors associated with a re-exploration included: receipt of blood transfusion (adjusted OR (95%CI) 8.25 (2.66-25.61)); use of a general anaesthetic (adjusted OR (95%CI) 3.33 (1.61-6.88)); pre-eclampsia (adjusted OR (95%CI) 3.27 (1.55-6.91)); black ethnicity (adjusted OR (95%CI) 3.14 (1.39-7.11)); postpartum haemorrhage (adjusted OR (95%CI) 2.82 (1.81-4.37)); use of anticoagulants or antiplatelet drugs pre-caesarean birth (adjusted OR (95%CI) 2.26 (1.35-3.81)); and emergency caesarean birth (adjusted OR (95%CI) 1.89 (1.01-3.57)).

CONCLUSION

Re-exploration following caesarean birth in the UK is uncommon but is associated with significant maternal morbidity and mortality. These study findings will help guide informed consent and encourage appropriate surveillance of high-risk women postpartum.

Obstetricians and midwives perspective of the alarming high cesarean section rates in Greece and worldwide

Introduction

This study aimed to outline the perspectives of obstetricians/gynecologists (physicians) and midwives regarding the alarmingly high rates of cesarean sections (CSs) to identify areas for improvement and describe the role of a regional obstetric quality initiative.

Material and methods

A cross-sectional study was performed utilizing real-world data from questionaries provided to Greek midwives and obstetricians. Primary outcomes included the attitudes of Greek physicians and midwives toward the CS rates in Greece and around the world, as well as identifying potential solutions for lowering these rates. The secondary outcome was the potential correlation between the answers of the participants and their demographic parameters.

Results

A total of 456 physicians and 234 midwives participated in the survey. Greek CS rates (>50 %) were considered "acceptable" and inevitable by 29.7 % and 32 % of the participants, respectively. Stratified analysis based on profession showed that significantly fewer midwives compared to obstetricians would agree with current CS rates. Participants who had obtained their degrees abroad were more likely to consider all CS rates more justified than physicians and midwives who had graduated from Greek medical schools. For all questions, the younger age subgroups responded in a way toward the non-acceptability of CS rates and favored the implementation of rules and practice control according to guidelines. The responses did not differ significantly between male and female physicians.

Conclusions

Greek midwives, to a greater degree than obstetricians/gynecologists, consider the current CS rates unjustified and agree on the importance of implementing appropriate interventions to reduce them.

The Collection and Application of Autologous Amniotic Fluid to Cesarean Delivery Closure

Background  Amniotic fluid and amnion membranes have been used in surgery specialties to improve wound healing and decrease surgical adhesion formation. Objective  The objective was to determine if amniotic fluid could be collected at cesarean delivery and then reapplied to the layers of the closure using the CeaLogic Specimen Collection and Ratio Applicator Kit. Study Design  Twenty pregnant individuals who met inclusion and exclusion criteria were enrolled. Amniotic fluid was collected at artificial rupture of the membranes using the collection kit. Autologous amniotic fluid was then transferred to the applicator kit, mixed with calcium chloride solution, and applied directly to each of the surgical repair layers during closure: closed hysterotomy incision, closed fascial incision, closed subcutaneous layer (if applicable), and closed skin. Subjects were then followed for six weeks. Photographs of the incision were taken immediately following surgery, one-week following surgery, and at the four-week postpartum visit. The Modified Hollander Cosmesis Score was used to assess wound appearance. Results  Twenty pregnant individuals who met inclusion and exclusion criteria were enrolled and all completed the study. The mean volume of amniotic fluid collected was 30 ± 19 mL. The median (IQR) Modified Hollander Cosmesis Score (Range 0-best, to 6-worst) at the one week and four-week postpartum visits was 0 (0,1) and 0 (0,2), respectively. There were no wound complications nor surgical site infections among the cohort. Further, there were no unscheduled visits for wound issues among any of the subjects. Conclusion  The CeaLogic Specimen Collection and Ratio Applicator Kits can be used to collect and reapply autologous amniotic fluid at the time of cesarean delivery. Future studies are needed to determine if the application of autologous amniotic fluid to cesarean delivery closure can improve cosmesis and wound healing, as well as decrease the risk for the development of intraabdominal adhesions.

Surgical transversus abdominis plane block with liposomal bupivacaine at cesarean: a pilot randomized trial

BACKGROUND

Postcesarean pain control is challenging. In addition to intrathecal morphine, recent studies have shown that liposomal bupivacaine administered via conventional transversus abdominis plane block reduces postcesarean opioid use. However, whether the administration of liposomal bupivacaine via a surgical approach also reduces opioid use is unknown.

OBJECTIVE

This study aimed to investigate whether the administration of liposomal bupivacaine via surgical transversus abdominis plane block (TAP block) reduces the cumulative dose of opioids administered in the first 48 hours after cesarean delivery among participants who also receive intrathecal morphine.

STUDY DESIGN

This was a pilot single-blind randomized controlled trial of 60 parturients undergoing cesarean delivery at a community tertiary referral hospital staffed by academic physicians. Immediately before fascial closure during cesarean delivery, a total of 80 mL of dilute bupivacaine plus liposomal bupivacaine or dilute bupivacaine alone was administered via surgical transversus abdominis plane block (40 mL on each side). The primary outcome was a median cumulative opioid dose received within the first 48 hours after cesarean delivery measured in morphine milligram equivalents. In addition, opioid use at other time points, pain scores, and participant satisfaction were assessed. A sample size of 60 was determined to be adequate to inform a potential future adequately powered randomized trial. The primary outcome of morphine milligram equivalents and pain scores were compared using a Wilcoxon rank-sum test.

RESULTS

Between October 11, 2021, and August 29, 2022, 60 participants were randomized and analyzed: 31 were allocated to liposomal bupivacaine plus regular bupivacaine (intervention group), and 29 were allocated to regular bupivacaine alone (control group). Participants allocated to the intervention group used a median cumulative dose of 2 morphine milligram equivalents of opioids (interquartile range, 0-24) in the first 48 hours compared with 8 morphine milligram equivalents (interquartile range, 0-40) among participants allocated to the control group (P=.236). The percentage of participants who used ≤15 morphine milligram equivalents of opioids was 61% in the intervention arm and 41% in the control arm (P=.123), and the percentage who used zero opioids was 45% in the intervention arm and 34% in the control arm (P=.399). The total number of opioid pills prescribed at discharge was fewer in the intervention arm than in the control arm (P=.029). Patient satisfaction with the intervention group and control group was similar.

CONCLUSION

Our pilot study suggests that liposomal bupivacaine administered via surgical transversus abdominis plane block is worth critical evaluation as an adjunctive analgesic modality in an adequately powered randomized trial.

L, Agiwal V, Angaali N, A. Y. N, D. S, Haggerty C, Reddy PS. Prospective cohort study of surgical site infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India

BACKGROUND

Caesarean section (CS) is considered to be a life-saving operative intervention for women and new-borns in certain antepartum and intrapartum conditions. Caesarean delivery may be accompanied by several complications including surgical site infections (SSI). However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries. The present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO at a tertiary care teaching hospital in Medchal, India. Also, to identify the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates.

MAIN OBJECTIVES

To estimate the incidence of surgical site infections (SSI's) according to CDC criteria following WHO-recommended single-dose antibiotic prophylaxis for caesarean section at a tertiary care teaching hospital in Medchal, India.

METHODS

A prospective hospital-based study was conducted between June 2017 and December 2019, in which women who underwent caesarean delivery were followed up for 30 days post-delivery. Clinical details were collected using a structured questionnaire, and participants were followed up weekly after discharge to document any signs and symptoms of SSI. Symptomatic patients were requested to come to the hospital for further investigation and treatment. Standard microbiological tests were conducted to detect microorganisms and their antibiotic sensitivity.

RESULTS

The study included 2,015 participants with a mean age of 24.1 years. The majority were multigravida (n = 1,274, 63.2%) and underwent emergency caesarean delivery (n = 1,232, 61.1%). Ninety two participants (4.6%, 95% CI: 3.7% to 5.6%) developed surgical site infections, with 91 (98.9%) having superficial and 1 (1.1%) having a deep infection. Among those who developed an SSI, 84 (91.3%) did so during their hospital stay, while 8 (8.7%) developed an SSI at home. The adjusted relative risk (a RR) for developing an SSI was 2.5 (95% CI: 1.4 to 4.6; power 99.9%) among obese women and 2.3 (95% CI: 1.1 to 4.7; power 100%) among women aged 25 years or younger. Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples. The most common organisms identified were Staphylococcus aureus (n = 7(12.3%)23, 46.0%), Klebsiella sp. (n = 13, 26.0%), and Escherichia coli (n = 12, 24.0%).

CONCLUSION

The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was low. Young women and obese women were at high risk of developing SSI.

Incisional Small-Bowel Strangulation after a Caesarean Section: A Case Report

Background and Objectives: Every surgical procedure has the possible risk of complications, and caesarean sections (CSs) are no exception. As CS rates are increasing worldwide, being familiar with rare but possible complications has become extremely important. Case report: We present a case of 25-year-old nulliparous patient who came to our hospital with twin pregnancy for a scheduled induction of labour. An urgent CS was performed due to labour dystocia. On the second postoperative day, the patient started to complain about pain in the epigastrium, but initially showed no signs of bowel obstruction, passing gas, and stools, and could tolerate oral intake. After a thorough examination, an early postoperative complication-small-bowel strangulation at the incision site-was diagnosed. Small bowels protruded in between sutured rectus abdominis muscle causing a strangulation which led to re-laparotomy. During the surgery, there was no necrosis of intestines, bowel resection was not needed, and abdominal wall repair was performed. After re-laparotomy, the patient recovered with no further complications. Conclusions: Although there are discussions about CS techniques, most guidelines recommend leaving rectus muscle unsutured. This case demonstrates a complication which most likely could have been avoided if the rectus muscle had not been re-approximated.

Ethical Development of Artificial Amniotic Sac and Placenta Technology: A Roadmap

In this paper we present an initial roadmap for the ethical development and eventual implementation of artificial amniotic sac and placenta technology in clinical practice. We consider four elements of attention: (1) framing and societal dialogue; (2) value sensitive design, (3) research ethics and (4) ethical and legal research resulting in the development of an adequate moral and legal framework. Attention to all elements is a necessary requirement for ethically responsible development of this technology. The first element concerns the importance of framing and societal dialogue. This should involve all relevant stakeholders as well as the general public. We also identify the need to consider carefully the use of terminology and how this influences the understanding of the technology. Second, we elaborate on value sensitive design: the technology should be designed based upon the principles and values that emerge in the first step: societal dialogue. Third, research ethics deserves attention: for proceeding with first-in-human research with the technology, the process of recruiting and counseling eventual study participants and assuring their informed consent deserves careful attention. Fourth, ethical and legal research should concern the status of the subject in the AAPT. An eventual robust moral and legal framework for developing and implementing the technology in a research setting should combine all previous elements. With this roadmap, we emphasize the importance of stakeholder engagement throughout the process of developing and implementing the technology; this will contribute to ethically and responsibly innovating health care.