Association of a low chest-to-head circumference ratio with breech or transverse lie: the Japan Environment and Children's Study

OBJECTIVE

We examined whether the chest-to-head circumference ratio at birth was associated with breech presentation and transverse lie. We also described the obstetric management of such pregnancies in the Japan Environment and Children's Study (JECS).

METHODS

We performed a cross-sectional evaluation of data collected between January 2011 and March 2014 in a nationwide prospective birth cohort study, the JECS. We analyzed 83,822 non-anomalous singletons born at 34-41 weeks' gestation to mothers with no history of previous cesareans or uterine surgery. We defined low, normal (reference group), and high chest-to-head circumference ratios as <10th percentile, 10th to 90th percentiles, and >90th percentile, respectively. Logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for breech presentation and transverse lie. The timing and mode of delivery of such pregnancies were examined.

RESULTS

Breech presentation was recorded in 2.6% and transverse lie in 0.2%. A low chest-to-head circumference ratio was associated with increased rate of breech presentation (5.2%; adjusted OR 2.36, 95% CI: 2.10-2.65) and transverse lie (0.3%; adjusted OR 2.33, 95% CI: 1.50-3.60), whereas a high ratio was linked to reduced breech presentation (1.1%; adjusted OR 0.51, 95% CI: 0.39-0.66). Subgroup analysis of children delivered by cesarean (n = 7971) showed a similar association, albeit with slightly reduced strength for breech presentation. Eighty-three percent of breech births and 46.3% of transverse lie births occurred at 37-38 weeks' gestation. Cesarean section was performed in 96.8% of breech presentations and 63.4% of transverse-lie ones.

CONCLUSIONS

These findings imply that the fetal chest-to-head circumference ratio may influence presentation at birth.

Congenital depressed skull fracture ("ping-pong" fracture) in newborn infants as a differential diagnosis of physical abuse

Depressed skull fractures without a clear explanation as to their origin point to trauma with a blunt object and suspected child abuse. In the case of newborn infants, their young age is a vulnerability factor and requires an exhaustive assessment. When child abuse is suspected, an assessment of the differential diagnoses is required to make the most appropriate intervention possible. Both an excessive intervention and an omission of a necessary intervention should be avoided. Congenital depressed skull fractures, described as "ping-pong fractures", are rare (0.3 to 2/10 000 births). They may appear without any trauma history or in instrumentalized childbirth. Here we describe the case of a newborn infant with a ping-pong fracture as an example of an accidental fracture.

Novel multidisciplinary cooperation model for obstetric medical quality control: A quasi-experimental study

OBJECTIVE

To explore the impact of a novel multidisciplinary cooperation model in obstetric medical quality control.

METHODS

This quasi-experimental study analyzed the quality indicators of full-term pregnant women who underwent vaginal trial labor in Zibo Maternal and Child Health Hospital between July 2021 and June 2022. The pregnant women were divided into two groups based on implementation of novel multidisciplinary cooperation: multidisciplinary and non-multidisciplinary. We compared the rate of labor analgesia, postpartum hemorrhage in vaginal delivery, transfer to cesarean section, and the 5-min Apgar score ≤7 in full-term neonates.

RESULTS

A total of 3751 pregnant women were enrolled into the study, of whom 2004 were included in the non-multidisciplinary group and 1747 in the multidisciplinary group. The analgesic rate of delivery of the multidisciplinary group was higher than that of the non-multidisciplinary group (P = 0.000). We established that the rate of postpartum bleeding (P = 0.040), transfer cesarean section (P = 0.003) and the incidence of Apgar score ≤7 in 5 min of full-term neonates (P = 0.038) of the multidisciplinary group was lower than that of the non-multidisciplinary group. There was no significant difference in the mean ages (29.40 ± 3.99 vs. 29.90 ± 4.27 years; P = 0.126), mean delivery gestational ages (39.65 ± 0.87 vs. 39.64 ± 1.06; P = 0.221), mean gravidity values (1.93 ± 1.09 vs. 2.00 ± 1.18; P = 0.586) and mean parity (1.40 ± 0.56 vs. 1.42 ± 0.59; P = 0.635) of the women in the two groups.

CONCLUSION

Multidisciplinary cooperation in delivery management can significantly improve some quality indicators. We established the analgesic rate of delivery can be increased and the rate of postpartum bleeding, transfer cesarean section and the incidence of Apgar score ≤7 in 5 min of full-term neonates can be decreased with the implementation of novel multidisciplinary cooperation.

Health care providers' perspectives on the mistreatment towards women during maternity care: Do perceptions of the working environment and empathy level matter?

BACKGROUND

Mistreatment of women in maternity care violates human rights, erodes trust and disrupts the continuity of maternal healthcare services. Investigating Health Care Providers' (HCPs) perspectives is indispensable in uncovering drivers and designing targeted interventions.

AIM

To identify the roles of HCPs' perceptions of the working environment and levels of empathy on the mistreatment of women during maternity care.

METHODS

We conducted a self-administered survey among 148 maternal HCPs practising in ten health centres and four hospitals in the East Wollega Zone, Western Ethiopia, from June to September 2022.

FINDINGS

Most providers reported seeing other HCPs mistreating women (93.2%), while three-fourths (75.7%) admitted it as their actions. Violation of privacy and confidentiality was the most frequently reported category of mistreatment (44.6%), followed by physical abuse (37.1%) and verbal abuse (35.8%). The likelihood of mistreating women was reduced by 65% (AOR=0.35, 95% CI: [0.14, 0.86]) among individuals with positive perceptions of their working environment compared to those with negative perceptions. A unit increase in providers' empathy also led to a five per cent decrease in mistreatment (AOR=0.95, 95% CI: [0.91, 0.98].

CONCLUSIONS

HCPs' perceptions of their working environment and enhanced empathy levels were associated with the reduction of the odds of mistreatment of women. While empathic care should be cultivated as a component of HCPs' competencies, efforts should be made to improve the conditions of the demanding health system to realise a resilient, motivated, competent, and compassionate workforce. The interplay between gender, profession, and mistreatment level requires further investigation.

First alongside midwifery led unit in a high complexity public hospital in Spain: Maternal and neonatal outcomes

PROBLEM

Midwifery led units are rare in Spain.

BACKGROUND

Midwife-Led Care (MLC) is a widely extended model of care and, within this, the alongside midwifery-led units (AMLU) are those hospital-based and located in close connection with obstetric units. In Spain, CL is the first center belonging to the National Health System of these characteristics.

AIM

To evaluate the first year of activity of this pioneering unit.

METHODS

An observational cross-sectional study was carried out to assess maternal and neonatal outcomes of births facilitated at CL by comparing with those births that fulfilled the criteria to be admitted at the AMLU but were assisted at the standard obstetric care unit of the hospital.

FINDINGS

174 (20,3%) women and birthing people decided to give birth at CL, whereas 684 (79,7%) gave birth at the Obstetric Unit of the Hospital. Women assisted at the AMLU had lower intervention rates (episiotomy, epidural analgesia) and a higher rate of breastfeeding practice. There were no statistical differences in maternal outcomes (postpartum hemorrhage, third-or-four-degree laceration) or neonatal outcomes (Apgar< 7 at 5 min; birth weight < 2500 gr; macrosomia; shoulder dystocia, neonatal care transfer).

DISCUSSION

There were differences in transfers from MLU to OU between nulliparous and multiparous; the main reason for transfer is the request for analgesia. Epidural analgesia should be considered when analyzing maternal outcomes.

CONCLUSION

An alongside midwifery-led unit is a safe option with a low incidence of complications. This model of care can be positively implemented at the Public Healthcare System.

Non-Obstetric Maternal Mortality Trends by Race in the United States

OBJECTIVES

Public health interventions to reduce maternal mortality have largely focused on obstetric causes of death. However, previous studies have noted that non-obstetrics factors, such as motor vehicle accidents, substance overdoses, homicides, and suicides, may account for a large proportion of maternal deaths. The study objective was to examine trends in maternal deaths from non-obstetric causes across races in the United States (US).

METHODS

A population-based cross-sectional study was conducted on 80,710,348 live births using data from the "Birth Data" and "Mortality Multiple Cause" files compiled by the Centers for Disease Control and Prevention from 2000 to 2019. The annual incidence of maternal deaths attributed to non-obstetric causes (/100,000 live-births) during pregnancy and up to 42 days postpartum were calculated across racial groups. Then the effects of race on the risk of non-obstetric maternal mortality and temporal changes over the study period were examined using logistic regression models.

RESULTS

From 2000 to 2019, a total 7,334 women died during pregnancy, childbirth, and within 42 days postpartum from non-obstetric causes, representing 34.5% (7,334/21,241) of all maternal mortality. Of non-obstetric deaths, 31.3% were caused by transport accidents and 27.3% by accidental poisoning. American Indian women were found to have the highest risk of non-obstetric maternal mortality (OR 2.20,95% CI 1.90-2.56), and 46.1% (176/382) of all deaths among pregnant American Indian women were caused by non-obstetric complications. Risk of non-obstetric maternal mortality increased overall during the 20-year study period, with a greater increase among Black (1.15, 1.13-1.17) and American Indian women (1.17, 1.13-1.21).

CONCLUSION

Non-obstetric causes of death have become increasingly prevalent in the US, especially in American Indian women. Novel interventions to address these non-obstetric factors should especially target American Indian women to improve maternal outcomes.

Evaluation of Elastic Venous Compression Device dispensation in pregnant and post-partum women using the French National Health Insurance Claims Database: The ProFIL retrospective cohort study

OBJECTIVES

To describe the real-world use of Elastic Venous Compression Devices (EVCDs) during pregnancy and post-partum using data from a representative subset of the French National Health Insurance Claims Database (the Echantillon Généraliste des Bénéficiaires, EGB).

STUDY DESIGN

Women aged 15-49 who were pregnant between 1st July 2017 and 15th June 2018 were identified in the EGB using pregnancy-specific acts (certain prenatal examinations or deliveries). Subgroups were defined by age, presence of Venous Thrombo-Embolism (VTE) risk factors, history of VTE, delivery type and time period. EVCD dispensations (format, prescriber, and date) were identified among those for "standard orthotics" using their unique reimbursement tariffs. Dispensation rates were computed for all subgroups, overall and by format and were compared.

RESULTS

15,528 pregnant women were included: 7,252 [46.7 %] deliveries (5,796 vaginal [79.9 %], 482 planned cesarean sections (C-sections) [6.7 %] and 974 unplanned C-Sections [13.4 %]), 2,734 (17.6 %) terminations and 5,542 (35.7 %) unknown outcomes. Overall, 4,919 (31.7 %) women were dispensed at least one EVCD. Ante-partum dispensation occurred in 43.1 % (n = 3,122) of women whose pregnancy led to a delivery. Dispensation rates were 17.3 % (n = 1,005), 46.7 % (n = 225) and 44.1 % (n = 430) after vaginal delivery, planned C-sections or unplanned C-sections, respectively. Overall, dispensation rates significantly increased with age, the presence of VTE risk factors, and a history of VTE (p < 0.01). EVCD dispensation was most frequent (17.0 %) during the 5th month of pregnancy. Among pregnant women who were dispensed at least one EVCD during ante- or post-partum, 69.0 % had one or two units of compression (27.1 % [one unit], 41.9 % [two units]). Stockings (48.6 %, n = 6,038) were dispensed significantly more frequently than socks (36.9 %, n = 4,586) and tights (14.5 %, n = 1,806) (p < 0.01). The main contributors to mechanical VTE prophylaxis were gynecologists (26.3 % of dispensations, n = 2,280), general practitioners (20.2 %, n = 1,749) and midwives (15.1 %, n = 1,314).

CONCLUSIONS

Low observed dispensation rates highlight a discrepancy between the French National Authority for Health (Haute Autorité de Santé, HAS), recommending EVCDs use during pregnancy and after delivery, and the real-life use of EVCD. Prescription sensitization combined with targeted information campaigns for pregnant women would be beneficial to contribute to the prevention of VTE, a health problem for pregnant women.

Effects of cord clamping timing in at-term elective cesarean section on maternal and neonatal outcomes: a randomized trial

PURPOSE

This study aimed to compare the effects of early cord clamping (ECC), delayed cord clamping (DCC), and umbilical cord milking (MC) on maternal and neonatal outcomes in elective cesarean births.

METHODS

We analyzed 204 women with uncomplicated at-term singleton pregnancies, who underwent cesarean birth under regional anesthesia between March and July 2021. The women were randomized into three groups: DCC (clamped 60 s postpartum), ECC (clamped within 15 s postpartum), or MC (clamped after milking five times) group. The neonatal and maternal outcomes of the groups were evaluated.

RESULTS

The duration of the operation was significantly lower (P < 0.001) in the MC group at 50 min (ECC, 60 min; DCC, 60 min), while intraoperative bleeding was significantly higher (P < 0.001) in the ECC group at 500 mL (DCC, 300 mL; MC, 225 mL). The rates of anemia and polycythemia significantly differed (P = 0.049) between the three groups. DCC and MC did not negatively affect maternal and neonatal outcomes compared with ECC.

CONCLUSION

DCC and MC are superior to ECC in terms of short-term maternal and neonatal outcomes in cases of elective cesarean birth under regional anesthesia.

Unplanned cesarean sections in advanced maternal age: A predictive model

INTRODUCTION

As maternal age during pregnancy is rising all over the world, there is a growing need for prognostic factors that determine maternal and perinatal outcomes in older women.

MATERIAL AND METHODS

This study is a retrospective cohort study of women aged 40 years or older at the time of delivery in four Santeon hospitals across the Netherlands between January 2016 and December 2019. Outcomes were compared between women of 40-44 years (advanced maternal age) and 45 years and older (very advanced maternal age). Primary outcome was unplanned cesarean section, secondary outcomes included postpartum hemorrhage and neonatal outcomes. Multivariate regression analysis was performed to analyze predictive factors for unplanned cesarean sections in women who attempted vaginal delivery. Subsequently, a predictive model and risk scores were constructed to predict unplanned cesarean section.

RESULTS

A cohort of 1660 women was analyzed; mean maternal age was 41.4 years, 4.8% of the women were 45 years and older. In both groups, more than half of the women had not delivered vaginally before. Unplanned cesarean sections were performed in 21.1% of the deliveries in advanced maternal age and in 29.1% in very advanced maternal age. Four predictive factors were significantly correlated with unplanned cesarean sections: higher body mass index (BMI), no previous vaginal delivery, spontaneous start of delivery and number of days needed for cervical priming. A predictive model was constructed from these factors with an area under the curve of 0.75 (95% confidence interval 0.72-0.78). A sensitivity analysis in nulliparous women proved that BMI, days of cervical priming, age, and gestational age were risk factors, whereas spontaneous start of delivery and induction were protective factors. There was one occurrence of neonatal death.

CONCLUSIONS

Women of advanced maternal age and those of very advanced maternal age have a higher chance of having an unplanned cesarean section compared to the general obstetric population in the Netherlands. Unplanned cesarean sections can be predicted through use of our predictive model. Risk increases with higher BMI, no previous vaginal delivery, and increasing number of days needed for cervical priming, whereas spontaneous start of labor lowers the risk. In nulliparous women, age and gestational age also increase risk, but induction lowers the risk of having an unplanned cesarean section.

Management of pregnancy and delivery in congenital fibrinogen disorders: communication from the ISTH SSC Subcommittee on Factor XIII and Fibrinogen

Congenital fibrinogen disorders (CFDs) are a heterogeneous group of rare congenital quantitative and/or qualitative fibrinogen deficiencies. The spectrum of molecular anomalies is broad, leading to several subtypes of fibrinogen disorders (ie, afibrinogenemia, hypofibrinogenemia, dysfibrinogenemia, and hypodysfibrinogenemia). Pregnancy in women with CFDs is a high-risk clinical situation, with an increased tendency for miscarriages, bleeding, and thrombosis. Even though it is well established that management of such pregnancies requires a multidisciplinary approach involving specialists (hematologists and maternal/fetal medicine experts with expertise in the management of inherited bleeding disorders), specific guidelines are lacking. In this International Society on Thrombosis and Haemostasis (ISTH) Scientific and Standardization Committee communication, we aim to propose an expert consensus opinion with literature evidence where available on the strategy for management of pregnancy, delivery, and puerperium in CFDs.

Factors associated with bypassing primary healthcare facilities for childbirth among women in Devchuli municipality of Nepal

BACKGROUND

It is crucial to deliver a child at nearby primary healthcare facilities to prevent subsequent maternal or neonatal complications. In low-resource settings, such as Nepal, it is customary to forgo the neighboring primary healthcare facilities for child delivery. Reports are scanty about the extent and reasons for bypassing local health centers in Nepal. This study sought to determine the prevalence and contributing factors among women bypassing primary healthcare facilities for childbirth.

METHOD

A community-based cross-sectional study was carried out in the Devchuli municipality of Nawalparasi East district of Nepal. Utilizing an online data collection tool, structured interviews were conducted among 314 mothers having a child who is less than one year of age.

RESULTS

This study showed that 58.9% of the respondents chose to bypass their nearest primary healthcare facility to deliver their babies in secondary or tertiary hospitals. Respondent's husband's employment status; informal employment (AOR: 4.2; 95% CI: 1.8-10.2) and formal employment (AOR: 3.2; 95% CI: 1.5-6.8), wealth quintile (AOR: 3.7; 95% CI: 1.7-7.7), parity (AOR): 3.0; 95% CI: 1.6-5.7], distance to nearest primary healthcare facility by the usual mode of transportation (AOR: 3.0; 95% CI: 1.5-5.6) and perceived service quality of primary healthcare facility (AOR: 3.759; 95% CI: 2.0-7.0) were associated with greater likelihood of bypassing primary healthcare facility.

CONCLUSION

Enhancing the quality of care, and informing beneficiaries about the importance of delivering children at primary healthcare facilities are essential for improving maternal service utilization at local primary healthcare facilities.

Birth preparedness and complication readiness among recently delivered women in Hargeisa town, Somaliland: A community-based cross-sectional study

BACKGROUND

About 287,000 mothers lost their lives due to pregnancy and delivery in 2020 worldwide. Birth preparedness and complication readiness (BPCR) is an approach used to utilize the timely use of skilled maternal and neonatal services. Preparing mothers for childbirth and against its dangers has great importance in reducing maternal mortality. Little is known about BPCR and influencing factors in Hargeisa town, Somaliland.

OBJECTIVE

To assess the level of BPCR and its associated factors among recently delivered women in Hargeisa.

METHODS

A community-based cross-sectional study was carried out in September 2022 among 300 women who delivered in the one-year time interval before the study period. A census was done to identify the women, and then they were selected by simple random sampling. Face-to-face interviews were conducted using a pre-structured questionnaire. A woman was considered prepared for birth if she made preparations for at least three of the BPCR components. Data were cleaned, entered, and analyzed using SPSS V.25. Bivariate and multivariate logistic regression analyses were performed with a cut-point of 0.05 significance level.

RESULTS

From a total of 300 women, 38.3% had good knowledge of BPCR, and only one-fourth (25%) were prepared for birth and its complications. Access and media usage (AOR = 9.64, CI 1.09-82.248), receiving health education about BPCR (AOR = 3.75, CI 1.01-13.87), giving birth at health institutions (AOR = 6.02, CI 1.39-25.95), and good knowledge of key danger signs of pregnancy (AOR = 0.017, CI 0.004-0.069) were factors significantly associated with BPCR practice.

CONCLUSION

The study identified that the BPCR level was very low compared to many other studies. Such a low BPCR level may have a negative impact on maternal health and lives, hindering interventions conducted to reduce maternal mortality rates. All concerned bodies should consider the importance of awareness creation regarding BPCR in their core interventions.

Incorporation, adaptation and rejection of obstetric practices during the implementation of the "Adequate Childbirth Program" in Brazilian private hospitals: a qualitative study

BACKGROUND

The "Adequate Childbirth Program" (PPA) is a quality improvement project that aims to reduce the high rates of unnecessary cesarean section in Brazilian private hospitals. This study aimed to analyze labor and childbirth care practices after the first phase of PPA implementation.

METHOD

This study uses a qualitative approach. Eight hospitals were selected. At each hospital, during the period of 5 (five) days, from July to October 2017, the research team conducted face to face interviews with doctors (n = 21) and nurses (n = 28), using semi-structured scripts. For the selection of professionals, the Snowball technique was used. The interviews were transcribed, and the data submitted to Thematic Content Analysis, using the MaxQda software.

RESULTS

The three analytical dimensions of the process of change in the care model: (1) Incorporation of care practices: understood as the practices that have been included since PPA implementation; (2) Adaptation of care practices: understood as practices carried out prior to PPA implementation, but which underwent modifications with the implementation of the project; (3) Rejection of care practices: understood as those practices that were abandoned or questioned whether or not they should be carried out by hospital professionals.

CONCLUSIONS

After the PPA, changes were made in hospitals and in the way, women were treated. Birth planning, prenatal hospital visits led by experts (for expecting mothers and their families), diet during labor, pharmacological analgesia for vaginal delivery, skin-to-skin contact, and breastfeeding in the first hour of life are all included. To better monitor labor and vaginal birth and to reduce CS without a clinical justification, hospitals adjusted their present practices. Finally, the professionals rejected the Kristeller maneuver since research has demonstrated that using it's harmful.

Fertility and self-rated health of migrant women of childbearing age-an analysis of moderating effects based on socioeconomic status

BACKGROUND

As fertility rates continue to decline and negative population growth emerges, China has sequentially introduced encouraging fertility policies to raise fertility levels. The impact of fertility on women's health remains inconclusive. It is essential to explore further the correlation between fertility and the health status of 113 million migrant women of childbearing age in China.

OBJECTIVE

To investigate how fertility affects the health status of migrant women of childbearing age and determine if migrant women's socioeconomic status plays a moderating role in this process.

METHODS

Using a nationally representative dataset from the 2018 China Migrants Dynamic Survey (CMDS), we examined the effects of fertility on the self-rated health of migrant women of childbearing age. An ordinary least squares regression model with moderating effects was used for the empirical study, and robustness tests were conducted based on the ordered probit model and propensity score matching to address endogeneity.

RESULTS

The empirical results indicated that a rise in the number of children born significantly reduces the self-rated health of migrant women of childbearing age. An increase in years of schooling and household income can significantly mitigate the negative impact of childbearing on the health of migrant women. The robustness of the above results was validated through alternative models and propensity score matching (PSM) methods. The heterogeneity analysis revealed that fertility exerts a negative impact on the health status of migrant women with rural household registration and on the health status of inter-provincial and inter-city migrant women. Further investigation found that the occurrence of childbirth during migration and an increase in the number of girls significantly negatively impacted the health status of migrant women. In contrast, the increase in the number of boys did not show a significant effect. Improving the health of migrant women of childbearing age significantly positively impacted their future childbearing intentions.

CONCLUSIONS

Migrant women of childbearing age bear the dual burden of migration and childbirth. Our findings showed the rise in the number of children born and the occurrence of childbirth during migration posed greater challenges to the health status of female migrants, particularly among those with lower socioeconomic status. Government and community efforts for enhancing health among migrant women of childbearing age are recommended.

Postpartum uterine involution promoted by penetrating-moxibustion therapy: a randomized controlled trial

OBJECTIVES

To observe the effect of penetrating-moxibustion therapy on postpartum uterine involution.

METHODS

Eighty puerpera were randomized into an observation group and a control group, 40 cases in each one. In the control group, oxytocin injection was administered by intravenous drip, 20 U each time, once daily. In the observation group, on the base of the treatment as the control group, the penetrating-moxibustion therapy was used at Shenque (GV 8), Qihai (CV 6) and Guanyuan (CV 4), 30 min to 40 min each time, twice a day. The intervention of each group started from the first day after childbirth and lasted 3 days. The uterine volume before and after treatment, and in 42 days of postpartum, the height decrease of the fundus of the uterus, the score of visual analogue scale (VAS) for uterine contraction, the volume of lochia rubra in 1 to 3 days of treatment, and lochia duration were compared between the two groups; and the clinical effect was evaluated.

RESULTS

The uterine volume in the observation group was smaller than that of the control group after treatment (P<0.01). In 1 to 3 days of treatment, the height decrease of the fundus of the uterus in the observation group was larger (P<0.01), VAS scores of uterine contraction were lower (P<0.05, P<0.01), the lochia rubra volume was less (P<0.01) than those in the control group. The duration of lochia rubra and lochia was shorter (P<0.01) in the observation group when compared with that of the control group. The favorable rate of uterine involution in the observation group was 95.0% (38/40), higher than that of the control group (75.0%, 30/40, P<0.05).

CONCLUSIONS

Penetrating-moxibustion therapy accelerates the recovery of the uterine volume, relieves uterine contraction, shortens the duration of lochia, reduces the lochia volume and promotes the postpartum uterine involution.

Patient-centered respectful maternity care: a factor analysis contextualizing marginalized identities, trust, and informed choice

BACKGROUND

Increasing rates of maternal mortality and morbidity, coupled with ever-widening racial health disparities in maternal health outcomes, indicate that radical improvements need to be made in the delivery of maternity care. This study explored the provision of patient-centered maternity care from the perspective of pregnant and postpartum people; experiences of respect and autonomy were examined through the multi-dimensional contexts of identity, relational trust, and protection of informed choices.

METHODS

We conducted primary data collection among individuals who experienced a pregnancy in the five years preceding the survey (N = 484) using the validated Mothers on Respect Index (MORi) and Mothers Autonomy in Decision Making (MADM) scale. We conducted an exploratory factor analysis (EFA) which produced three factor variables: trust, informed choice, and identity. Using these factor variables as dependent variables, we conducted bivariate and multivariate analysis to examine the relationship between these factor variables and social marginalization, as measured by race, disability, justice-involvement, and other social risk factors, such as food and housing insecurity.

RESULTS

Results of our bivariate and multivariate models generally confirmed our hypothesis that increased social marginalization would be associated with decreased experiences of maternity care that was perceived as respectful and protective of individual autonomy. Most notably, AI/AN individuals, individuals who are disabled, and individuals who had at least one social risk factor were more likely to report experiencing identity-related disrespect and violations of their autonomy.

CONCLUSIONS

In light of the findings that emphasize the importance of patient identity in their experience in the healthcare system, patient-centered and respectful maternity care must be provided within a broader social context that recognizes unequal power dynamics between patient and provider, historical trauma, and marginalization. Provider- and facility-level interventions that improve patient experiences and health outcomes will be more effective if they are contextualized and informed by an understanding of how patients' identities and traumas shape their healthcare experience, health-seeking behaviors, and potential to benefit from clinical interventions and therapies.

Determinants of respectful maternity care among women who gave childbirth in Southern Ethiopia

BACKGROUND

Having a good provision of respectful maternity care (RMC) to a woman who gives childbirth is a crucial component of maternal health care to result in positive maternal and neonatal outcomes. Disrespect and lack of women-centered care in birth discourage a woman from seeking healthcare during childbirth contributing to poor healthcare-seeking behaviour and dissatisfaction with the maternity service. The current study aimed to assess key determinants of RMC during childbirth at selected public health facilities of the Gofa zone, Southern Ethiopia.

METHODS

A cross-sectional study design was conducted from March to April 2021 among 390 women who gave birth in eight randomly selected public health facilities of Gofa zone, Southern Ethiopia. The level of RMC was measured using structured exit interview items. A structured-interviewer-administered questionnaire was used to collect data and then entered into Epi-data version 4.6 and exported to SPSS version 25 for further analysis. Bivariate and multivariate logistic regression analyses were used to identify determinants of RMC among women.

RESULTS

A total of 390 women responded to the exit interview making a response rate of 100%. The mean (± SD) age of the 390 women was 27.9 (± 4.85) years. The overall prevalence of women who received RMC was 40.5%, 95% CI (36-45%). Two hundred and ninety-seven (76.2%; n = 297/390) women had antenatal care (ANC) attendance in the index pregnancy. A woman who had planned pregnancy (AOR = 1.72, CI: 1.04, 2.85), planned to deliver in a health facility (AOR = 1.68, CI: 1.00, 2.81), presence of familial support (AOR = 2.04, CI: 1.20, 3.48), and had information about service availability (AOR = 4.44, CI: 2.09, 9.42) were associated with RMC among women.

CONCLUSION

The provision of respectful maternity care in the study area was low when compared with local studies. Planned pregnancy, plan to deliver in a health facility, family support, and presence of information about service availability were factors associated with RMC among women. More attention should be given to training and supportive supervision of health care professionals on respectful maternity care and its standards to increase service uptake and make service more women-centred.

Analysis of the obstetrician's posture and movements during a simulated forceps delivery

BACKGROUND

The objective of this study was to identify and qualify, by means of a three-dimensional kinematic analysis, the postures and movements of obstetricians during a simulated forceps birth, and then to study the association of the obstetricians' experience with the technique adopted.

METHOD

Fifty-seven volunteer obstetricians, 20 from the Limoges and 37 from the Poitiers University hospitals, were included in this multi-centric study. They were classified into 3 groups: beginners, intermediates, and experts, beginners having performed fewer than 10 forceps deliveries in real conditions, intermediates between 10 and 100, and experts more than 100. The posture and movements of the obstetricians were recorded between December 2020 and March 2021 using an optoelectronic motion capture system during simulated forceps births. Joint angles qualifying these postures and movements were analysed between the three phases of the foetal traction. These phases were defined by the passage of a virtual point associated with the forceps blade through two anatomical planes: the mid-pelvis and the pelvic outlet. Then, a consolidated ascending hierarchical classification (AHC) was applied to these data in order to objectify the existence of groups of similar behaviours.

RESULTS

The AHC distinguished four different postures adopted when crossing the first plane and three different traction techniques. 48% of the beginners adopted one of the two raised posture, 22% being raised without trunk flexion and 26% raised with trunk flexion. Conversely, 58% of the experts positioned themselves in a "chevalier servant" posture (going down on one knee) and 25% in a "squatting" posture before initiating traction. The results also show that the joint movement amplitude tends to reduce with the level of expertise.

CONCLUSION

Forceps delivery was performed in different ways, with the experienced obstetricians favouring postures that enabled observation at the level of the maternal perineum and techniques reducing movement amplitude. The first perspective of this work is to relate these different techniques to the traction force generated. The results of these studies have the potential to contribute to the training of obstetricians in forceps delivery, and to improve the safety of women and newborns.

Geographical distribution of emergency obstetric and neonatal care signal functions in Ethiopian health facilities: 2021-2022 Ethiopian service Provision Assessment (SPA)

BACKGROUND

The maternal mortality ratio in Ethiopia is still high, with an estimate of 412 deaths per 100,000 live births in 2016. Signal functions for emergency obstetric and neonatal care must be accessible and usable in order to successfully prevent maternal deaths. It is an important strategy to reduce maternal and newborn morbidity and mortality in countries with limited resources. Hence, an assessment of the availability of fully functioning EmONC services and their coverage per 500,000 people in Ethiopia is crucial.

METHODS

This study is a retrospective analysis of data from the Ethiopian Service Provision Assessment Survey (ESPA), a national-level survey data source. Data collection for the survey took place from August 11, 2021, to February 4, 2022. For this investigation, 905 healthcare facilities in total were evaluated for the availability of emergency obstetric and new-born care (EmONC) services at all hospitals, selected health centers, and private clinics were evaluated. Descriptive data analysis was done by the using statistical package for social science version 26 (SPSS) to run frequency and cross-tabs. Global Positioning System (GPS) (arc map 10.8) Software was used for spatial distribution in order to locate the physical accessibility of EmONC providing health facilities on flat map surfaces. It was projected based on Ethiopia's geographic coordinate system at Adindan UTM zone 370N.

RESULTS

Of 905 health facilities, only 442 (49%) could provide fully functioning BEmONC, and 250 (27.6%) health facilities have been providing fully functioning CEmONC. The overall coverage of BEmONC ratios in Ethiopia is 1.5-3.77 per 500,000 population and CEmONC (0.83-2.1) per 500,000 populations. Regions such as Amhara, SNNPR and Addis Ababa had found to have high BEmONC ratio. The geographical distribution of the EmONC showed that the central areas of the country, such as southwest Shewa and east Shewa, the Oromia region, the northern areas of the South Nation, nationalities, and peoples regions (SNNPR), including the Gurage zone and the Wolaita-Soddo zone, and the middle areas in the Amhara region (west Gojjam or around Bahir Dar town), and the southern areas, Debra Tabor and Debre Birhane zones, all had greater access to facilities offering complete EmONC services.

CONCLUSION

Comprehensive emergency obstetrics and neonatal care (CEmONC) in Ethiopia met WHO recommendations, despite basic emergency obstetric and neonatal care (BEmONC) falling below those standards in Ethiopia. There are extremely large disparities in the accessibility of both basic and comprehensive emergency obstetrics and neonatal care in Ethiopia. Thus, Strategic planning is needed to improve infrastructures and inputs for EmONC services, particularly in remote areas of the country. Additionally, private facilities ought to place a priority on the provision of these services.

Trends in Attempted Vaginal Delivery among Pregnancies Complicated by Gastroschisis, 2014 to 2020

OBJECTIVE

 Gastroschisis is a full-thickness congenital defect of the abdominal wall through which intestines and other organs may herniate. In a prior analysis, attempted vaginal delivery with fetal gastroschisis appeared to increase through 2013, although cesarean delivery remained common. The objective of this analysis was to update current trends in attempted vaginal birth among pregnancies complicated by gastroschisis.

STUDY DESIGN

 We performed an updated cross-sectional analysis of live births from 2014 and 2020 using data from the U.S. National Vital Statistics System and evaluated trends in attempted vaginal deliveries among births with gastroschisis. Trends were evaluated using joinpoint regression. We constructed logistic regression models to evaluate the association between demographic and clinical variables and attempted vaginal delivery in the setting of gastroschisis.

RESULTS

 Among 5,355 deliveries with gastroschisis meeting inclusion criteria, attempted vaginal delivery increased significantly from 68.9% to 75.1%, an average annual percent change of 1.7% (95% confidence interval [CI], 0.8-2.5). Among gastroschisis-complicated pregnancies, patients 35 to 39 years old (adjusted odds ratio [aOR], 0.53; 95% CI, 0.37-0.79) and Hispanic race/ethnicity (aOR, 0.69; 95% CI, 0.58-0.62) were at lower likelihood of attempted vaginal delivery in adjusted analyses.

CONCLUSION

 These findings suggest that vaginal delivery continues to increase in the setting of gastroschisis. Further reduction of surgical delivery for this fetal defect may be possible.

KEY POINTS

· Vaginal deliveries increased among gastroschisis pregnancies.. · Hispanic patients were less likely to attempt vaginal delivery.. · Some gastroschisis pregnancies still deliver surgically..

Validation of a Predictive Model of Vaginal Birth after Caesarean Section in Pakistani Women

OBJECTIVE

To determine the frequency of successful trials of vaginal birth after Caesarean section (VBAC) using the Flamm and Geiger model.

STUDY DESIGN

Observational study. Place and Duration of the Study: Obstetrics and Gynaecology Unit II of Dr. Ruth K.M. Pfau Civil Hospital, Karachi, Pakistan, from August 2022 to January 2023.

METHODOLOGY

Women with singleton pregnancy having cephalic presentation, previous one lower segment caesarean section (LSCS), and without any contraindication for vaginal delivery were included. Women bearing foetus having estimated weight >3.5kg, morbid obesity, multiple pregnancies, non-cephalic presentation, placenta praevia, abruptio placentae, uncontrolled maternal comorbidities, or had previous two or more Caesarean sections were excluded. Flamm and Geiger score was applied to record observations of successful and unsuccessful trials. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the score were calculated by ROC curve, along with its area under the curve (AUC) and Youden's index curve, with 95% confidence interval.

RESULTS

This study included 258 participants. Successful vaginal delivery was possible in 125 (48.4%) participants, whereas 133 (51.6%) underwent emergency Caesarean section. Cervical dilatation and effacement were the main factors assessing the success. The Flamm and Geiger score of >5 had an area under the curve of 0.813 (0.762-0.864). The score's sensitivity was 75% (67-82%), specificity 76% (68-82%), and PPV of 75% with an accuracy of 76%.

CONCLUSION

The Flamm and Geiger score of >5 demonstrated high sensitivity, specificity, PPV, and accuracy in predicting later successful vaginal birth. It is recommended as a promising and valuable tool for assessing VBAC's success in low-resource countries.

KEY WORDS

Vaginal birth after caesarean, Flamm and Geiger Model, Indication of caesarean, trial of labour after caesarean, VBAC risk scoring criteria.

Intrauterine Device Placement Success for Adolescents and Young Adults at Community-Based Reproductive Health Clinics

BACKGROUND

Despite the endorsement of intrauterine device (IUD) use in adolescents and young adults (AYAs) by leading professional organizations and demonstrated acceptance and desirability by AYAs, clinicians may worry about the procedural difficulty of IUD device placement in younger patients.

OBJECTIVE

The aim of this study was to evaluate the clinical outcomes of first-attempt IUD placement in an AYA population by vaginal delivery (VD) history.

STUDY DESIGN

We performed a retrospective cohort study of patients under 25 years old at reproductive health clinics with an IUD placement attempt between January 1 and August 31, 2017. We abstracted sociodemographic characteristics, pregnancy history, and procedural characteristics including complications. Bivariate analyses compared successful first-attempt IUD placement by VD history. We also assessed the frequency of secondary clinical outcomes including ancillary measures used, provider type, symptoms reported during the procedure, and complications.

RESULTS

We included 1325 participants (median age = 21.3 years), including 42 (3.2%) with a previous VD. Nearly all IUD placements were successful on the first attempt (n = 1301, 98.2%) and performed by advanced practice clinicians (n = 1314, 99.2%). First-attempt IUD placement success was similar in those participants with and without VD (P > .999). Ancillary measures other than nonsteroidal anti-inflammatory drugs were used infrequently (n = 16, 3.6%). Among participants with an unsuccessful placement, 66.7% returned, and all had a successful IUD placement on the second attempt. Documented complications within 6 months of placement were rare (n = 29) and mostly comprised expulsions (n = 27, 93.1%).

CONCLUSION

IUD placement success among AYAs at community-based reproductive health clinics is high and is not associated with a history of VD.

Obstetric violence and LGBTQIA+phobia: interlaced oppressions and violations

The cisheteropatriarchal capitalist system has developed by class, racial and sexual oppression and exploitation in establishing unequal, hierarchical power relations. One of these kinds of oppression involves the use of violence against bodies considered wayward and transgressive within this structure. Of the different types of violence, this study focused on obstetric violence, understood as patriarchal gender violence designed to remove the rights, autonomy and agency of trans women and men during the processes of pregnancy, childbirth, postpartum and abortion. This article reflects on obstetric violence and its impacts on homo-parenthood for lesbian women and trans men, on the understanding that the LGBTQIA+ population is one of the most vulnerable and removed from health services, mainly because of the institutional violence suffered by these bodies. Accordingly, the intention is to understand, through social and historical analysis, how these sexist, heteropatriarchal violations, interlacing and reflecting in health care for these people, generate even more forms of oppression against this population.

Disparities in Mistreatment During Childbirth

Importance

Lack of respectful maternity care may be a key factor associated with disparities in maternal health. However, mistreatment during childbirth has not been widely documented in the US.

Objectives

To estimate the prevalence of mistreatment by health care professionals during childbirth among a representative multistate sample and to identify patient characteristics associated with mistreatment experiences.

Design, Setting, and Participants

This cross-sectional study used representative survey data collected from respondents to the 2020 Pregnancy Risk and Monitoring System in 6 states and New York City who had a live birth in 2020 and participated in the Postpartum Assessment of Health Survey at 12 to 14 months' post partum. Data were collected from January 1, 2021, to March 31, 2022.

Exposures

Demographic, social, clinical, and birth characteristics that have been associated with patients' health care experiences.

Main Outcomes and Measures

Any mistreatment during childbirth, as measured by the Mistreatment by Care Providers in Childbirth scale, a validated measure of self-reported experiences of 8 types of mistreatment. Survey-weighted rates of any mistreatment and each mistreatment indicator were estimated, and survey-weighted logistic regression models estimated odds ratios (ORs) and 95% CIs.

Results

The sample included 4458 postpartum individuals representative of 552 045 people who had live births in 2020 in 7 jurisdictions. The mean (SD) age was 29.9 (5.7) years, 2556 (54.4%) identified as White, and 2836 (58.8%) were commercially insured. More than 1 in 8 individuals (13.4% [95% CI, 11.8%-15.1%]) reported experiencing mistreatment during childbirth. The most common type of mistreatment was being "ignored, refused request for help, or failed to respond in a timely manner" (7.6%; 95% CI, 6.5%-8.9%). Factors associated with experiencing mistreatment included being lesbian, gay, bisexual, transgender, queer identifying (unadjusted OR [UOR], 2.3; 95% CI, 1.4-3.8), Medicaid insured (UOR, 1.4; 95% CI, 1.1-1.8), unmarried (UOR, 0.8; 95% CI, 0.6-1.0), or obese before pregnancy (UOR, 1.3; 95% CI, 1.0-1.7); having an unplanned cesarean birth (UOR, 1.6; 95% CI, 1.2-2.2), a history of substance use disorder (UOR, 2.6; 95% CI, 1.3-5.1), experienced intimate partner or family violence (UOR, 2.3; 95% CI, 1.3-4.2), mood disorder (UOR, 1.5; 95% CI, 1.1-2.2), or giving birth during the COVID-19 public health emergency (UOR, 1.5; 95% CI, 1.1-2.0). Associations of mistreatment with race and ethnicity, age, educational level, rural or urban geography, immigration status, and household income were ambiguous.

Conclusions and Relevance

This cross-sectional study of individuals who had a live birth in 2020 in 6 states and New York City found that mistreatment during childbirth was common. There is a need for patient-centered, multifaceted interventions to address structural health system factors associated with negative childbirth experiences.

Refugee women's and providers' perceptions of person-centered maternity care: a qualitative study in two refugee camps in Chad

BACKGROUND

Globally, mistreatment of women during labor and delivery is a common human rights violation. Person-centered maternity care (PCMC), a critical component of quality of care, is respectful and responsive to an individual's needs and preferences. Factors related to poor PCMC are often exacerbated in humanitarian settings.

METHODS

We conducted a qualitative study to understand Sudanese refugee women's experiences, including their perceptions of quality of care, during labor and delivery at the maternities in two refugee camps in eastern Chad, as well as maternity health workers' perceptions of PCMC and how they could be better supported to provide this. In-depth interviews were conducted individually with 22 women who delivered in the camp maternities and five trained midwives working in the two maternities; and in six dyads with a total of 11 Sudanese refugee traditional birth attendants and one assistant midwife. In addition, facility assessments were conducted at each maternity to determine their capacity to provide PCMC.

RESULTS

Overall, women reported positive experiences in the camp maternities during labor and delivery. Providers overwhelmingly defined respectful care as patient-centered and respect as being something fundamental to their role as health workers. While very few reported incidents of disrespect between providers and patients in the maternity, resource constraints, including overwork of the providers and overcrowding, resulted in some women feeling neglected.

CONCLUSIONS

Despite providers' commitment to offering person-centered care and women's generally positive experiences in this study, one of few that explored PCMC in a refugee camp, conflict and displacement exacerbates the conditions that contribute to mistreatment during labor and delivery. Good PCMC requires organizational emphasis and support, including adequate working conditions and ensuring suitable resources so health workers can effectively perform.

The effect of using birth ball and squatting position during labor on pain, duration, and satisfaction: A randomized controlled trial

AIM

The aim of this study is to assess the effect of using a birth ball and squatting position during labor on labor pain, duration of labor, and satisfaction.

METHODS

This study is a randomized controlled experimental trial. It was conducted in the delivery unit of Başakşehir Çam and Sakura City Hospital. The study sample consisted of a total of 159 women, 53 in the birth ball application room, 53 in the squatting position group, and 53 in the control group. The "Information Form," "Visual Analog Scale," "Partograph," and "Maternal Satisfaction Assessment at Delivery Scale-Normal Birth" were used in the data collection. Data were analyzed using analysis of variance, Pearson's Chi-square test, Pillai's trace test.

RESULTS

The present study revealed that the pain perception level was lower in the birth ball and squatting position groups compared to the control group, and there was a statistically significant difference between them (p < .05). The duration of the first and second stages of labor and the total duration of labor decreased in the birth ball and squatting position groups (p < .05). The difference was statistically significant in comparing the level of satisfaction (p < .05). It was found that the highest satisfaction was in the birth ball group.

CONCLUSION

Using a birth ball and squatting position during labor are effective methods of reducing labor pain, shortening the duration of labor, and increasing the level of satisfaction. There is a need for more studies on the effects of the birth ball and squatting position.

CLINICALTRIALS

gov Identifier: NCT05360823.

Deliveries in Lebanon, the Country with the Highest Refugee Density in the World: A Descriptive Review

PURPOSE

The aim of this study is to analyze obstetrical and reproductive health parameters in Lebanon from 2015 until 2018 in the setting of the Syrian refugee influx in order to evaluate potential risks and provide a management plan to improve outcomes.

DESCRIPTION

Data from the Lebanese Ministry of Public Health (LMPH) on all obstetrical deliveries that occurred in Lebanon between 2015 and 2018 was screened and analyzed. Number and mode of delivery as well as maternal and neonatal outcomes were included. Joinpoint regression analysis was used for trends of selected parameters. Independent two-sample t-tests were used for comparisons.

ASSESSMENT

Women of non-Lebanese nationality residing in Lebanon had a significantly greater number of total deliveries (p-value < 0.001), vaginal deliveries (p-value = 0.002), cesarean sections (p-value = 0.02). When looking at delivery trends from 2015 to 2018, Lebanese women had a significant decrease in total number of deliveries (p-value < 0.001) and vaginal deliveries (p-value < 0.001).

CONCLUSION

Total number of deliveries and cesarean sections is on the rise in Lebanon. Cesarean section practice should be audited by the LMPH and the Lebanese Order of Physicians (LOP). Local and international agencies should prioritize the implementation and management of family planning facilities in refugee hosting countries.

Relationship between maternal antenatal attachment and traumatic childbirth perception among pregnant women

OBJECTIVE

To examine the relationship between the perception of traumatic birth and maternal attachment in pregnant women.

METHODS

This descriptive and correlational study recruited 370 pregnant women who applied for an antenatal visit to outpatient clinics of a state hospital. The data were collected using a Personal Information Form, Maternal Antenatal Attachment Scale (MAAS), and Traumatic Birth Perception Scale (TBPS). Data were collected using the face-to-face method. The study was reported according to the STROBE.

RESULTS

The mean total score of MAAS was 75.71 ± 7.72 and the mean TBPS score was 73.21 ± 28.34. Normal birth pain was perceived as "severe" by 38.3% of pregnant women and as "very severe" by 46.1%. It was determined that 29.2% of pregnant women had a "high" level of traumatic birth perception and 14.5% had a "very high" level. A negative correlation was found between the mean scores of MAAS and TBPS of pregnant women. The trimester of pregnancy, listening to the birth story, planned pregnancy, and traumatic birth perception, was a significant predictor of maternal antenatal attachment.

CONCLUSION

As the maternal antenatal attachment levels of pregnant women increased, their perceptions of traumatic birth decreased.

How does gestational weight gain influence short- and long-term postpartum weight retention? An updated systematic review and meta-analysis

This systematic review and meta-analysis provide an update of an earlier meta-analysis examining the impact of gestational weight gain (GWG) on postpartum weight retention (PPWR). Thirty-four observational studies were included, and results from 18 studies were combined in meta-analyses. We found that women with excessive GWG retained an additional 2.98 kg (95% CI: 0.59, 5.37 kg, I2  = 91%) at 0.5 years, 1.89 kg (95% CI: 0.90, 2.88 kg, I2  = 61%) at > 0.5-1 year and 2.89 kg (95% CI: 1.74, 4.04 kg, I 2  = 0%) at 2-4 years, compared to women who met the National Academy of Medicine GWG recommendations. Moreover, synthesis of confounder-adjusted regression coefficients showed that each 1 kg increase of GWG corresponded to 0.62 kg (95% CI: 0.22, 1.02 kg, I2  = 96%) additional PPWR at 6-9 months, 0.48 kg (95% CI: 0.14, 0.81 kg, I2  = 93%) at 1-3 years, and 0.31 kg (95% CI: -0.24, 0.86 kg, I2  = 89%) at 5-7 years postpartum. Findings suggest that higher GWG contributes to increased maternal body weight in the short- and long-term after childbirth, independent of prepregnancy body mass index. The heterogeneity of reported data and methodological differences across studies complicate the ability to synthesize data and interpret findings.

Survey of Neonatal Management After Amnioinfusion for Anhydramnios

This survey study reports on use of renal replacement therapy, hemodynamic support, sedation, neuroimaging, and extracorporeal membrane oxygenation at Renal Anhydramnios Fetal Therapy trial sites for neonates with either bilateral renal agenesis or fetal kidney failure.

Vacuum-assisted delivery outcomes: is advanced maternal age a factor?

PURPOSE

This study evaluated age-related maternal outcomes of vacuum-assisted vaginal deliveries (VAD).

METHODS

This retrospective cohort study included all nulliparous women with singleton VAD in one academic institution. Study group parturients were maternal age ≥ 35 years and controls < 35. Power analysis revealed that 225 women/group would be sufficient to detect a difference in the rate of third- and fourth-degree perineal tears (primary maternal outcome) and umbilical cord pH < 7.15 (primary neonatal outcome). Secondary outcomes were maternal blood loss, Apgar scores, cup detachment, and subgaleal hematoma. Outcomes were compared between groups.

RESULTS

From 2014 to 2019, 13,967 nulliparas delivered at our institution. Overall, 8810 (63.1%) underwent normal vaginal delivery, 2432 (17.4%) instrumental, and 2725 (19.5%) cesarean. Among 11,242 vaginal deliveries, 10,116 (90%) involved women < 35, including 2067 (20.5%) successful VAD vs. 1126 (10%) women ≥ 35 years with 348 (30.9%) successful VAD (p < 0.001). Rates of third- and fourth-degree perineal lacerations were 6 (1.7%) with advanced maternal age and 57 (2.8%) among controls (p = 0.259). Cord pH < 7.15 was similar: 23 (6.6%) study group and 156 (7.5%) controls (p = 0.739).

CONCLUSION

Advanced maternal age and VAD are not associated with higher risk for adverse outcomes. Older, nulliparous women are more likely to undergo vacuum delivery than younger parturients.

Patient perception of labor support behaviors provided by Finnish midwives

BACKGROUND

Almost all births in Finland occur in hospitals, but the concept of labor support behavior is not well-known among Finnish midwives.

OBJECTIVE

The primary aim was to increase perceived labor support as measured by BANSILQ.

METHODS

This study was tailored to evaluate the impacts of short on-the-job training interventions for midwives (n=70) in labor support given to mothers. The training was conducted at one university hospital and and one regional hospital during 2012. The trainings were carried out twice at both hospitals to reach as many miwdwives as possible to participate. Two university hospitals-one regional and one central-were selected as controls. New mothers were asked to complete the Bryanton Adaptation of the Nursing Support in Labor Questionnaire (BANSILQ) in the postpartum wards at all the selected hospitals before the intervention (n=1500) and after the intervention (n=1500). The data were linked to the Finnish Medical Birth Register (MBR). As this is an in-job training intervention study and not a trial, it has not been registered in a trial registry.

RESULTS

The response rate was 68% (n=1020) for the pre-intervention survey and 47% (n=704) for the post-intervention survey. At the regional-level intervention hospital, the mean length of the second stage of childbirth decreased significantly. A bonding time of at least three minutes was three times more likely at both intervention hospitals. Support for breastfeeding was twice as likely at the university-level hospital after the intervention. In all the study hospitals, mothers with less education were more likely to receive tangible and informal support than highly educated mothers.

CONCLUSIONS

This short on-the-job intervention did not increase labor support provided by Finnish midwives in its entirety, and the effect on birth outcomes was minimal. However, support for breastfeeding increased, and some types of support were targeted at those who needed it most. To improve midwifery care, both training and sufficient resources are needed.

Single-dose oral azithromycin prophylaxis in planned vaginal delivery for sepsis prevention: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The use of oral azithromycin (AZI) as a preventive measure against postpartum infections of planned vaginal births has garnered a lot of interest in recent years and has been the subject of many randomized controlled trials (RCTs). However, the results from these trials have not been consistent. Therefore, we aim to perform a systematic review and meta-analysis to determine whether the use of a single-dose of oral AZI is clinically significant.

METHODS

We systematically searched PubMed, Embase, and Cochrane Central for RCTs from May to June 2023, comparing a single dose of oral AZI with placebo in patients undergoing planned vaginal delivery at a minimum of 28 weeks of gestational age. The main outcomes were puerperal and neonatal sepsis. Statistical analyses were performed using Review Manager 5.4.1 (Cochrane Collaboration). Heterogeneity was assessed with I2 statistics.

RESULTS

Four RCTs were included (mothers, n = 42 235; newborns n = 42 492). Approximately 49.8% of mothers received a single dose of oral AZI for sepsis prophylaxis. Compared with placebo, AZI significantly reduced the incidence of puerperal sepsis (risk ratio [RR], 0.65 [95% confidence interval (CI), 0.55-0.77]; P < 0.001), mastitis or breast abscess (RR, 0.58 [95% CI, 0.42-0.79]; P < 0.001), endometritis (RR, 0.65 [95% CI, 0.54-0.77]; P < 0.001), wound infection (RR, 0.81 [95% CI, 0.69-0.96]; P = 0.013), infection rate (RR, 0.62 [95% CI, 0.51-0.76]; P < 0.001), and fever (RR, 0.50 [95% CI, 0.28-0.89]; P = 0.018) in mothers. No statistically significant differences were identified between groups regarding maternal all-cause mortality and the use of prescribed postpartum antibiotics. Similarly, no statistical differences were noted in the neonatal group regarding sepsis, infection rate, and all-cause mortality.

CONCLUSION

AZI appears to be an effective preventive measure against many postpartum infections in mothers but a substantial impact on neonatal outcomes has not yet been conclusively observed.

Evaluating tranexamic acid for the prevention and treatment of obstetric hemorrhage

PURPOSE OF REVIEW

Tranexamic acid (TXA) has emerged as a promising pharmacological adjunct to treat and prevent postpartum hemorrhage (PPH). We provide an overview of TXA, including its pharmacology, key findings of randomized trials and observational studies, and critical patient safety information.

RECENT FINDINGS

Pharmacokinetic data indicate that TXA infusions result in peak plasma concentration within 3 min (range: 1-6.6 min). Ex-vivo pharmacodynamic data suggest that low-dose TXA (5 mg/kg) inhibits maximum lysis for at least 1 h. In predominantly developing countries, TXA has demonstrated a 19% reduction in the risk of bleeding-related death among patients with PPH. Based on high-quality randomized trials, TXA prophylaxis does not effectively reduce the risk of PPH during vaginal delivery and is likely ineffective in reducing the PPH risk during cesarean delivery. TXA exposure does not increase the risk of maternal thrombotic events. Maternal deaths have occurred from accidental intrathecal TXA injection from look-alike medication errors.

SUMMARY

TXA has shown promise as an important adjunct for PPH treatment, especially in low-resource settings. However, TXA is not recommended as PPH prophylaxis during vaginal or cesarean delivery. Patient safety initiatives should be prioritized to prevent maternal death from accidental intrathecal TXA injection.

A Randomized Controlled Trial of a 30- versus a 120-Second Delay in Cord Clamping after Term Birth

OBJECTIVE

 Delayed cord clamping (DCC) has been recently adopted in neonatal resuscitation. The immediate cardiac hemodynamic effects related to DCC more than 30 seconds was not studied. We aimed to study the effect of DCC at 120 seconds compared with 30 seconds on multiple hemodynamic variables in full-term infants using an electrical cardiometry (EC) device.

STUDY DESIGN

 Present study is a randomized clinical trial. The study was conducted with full-term infants who were delivered at the Obstetrics and Gynecology Department in Cairo University Hospital. Sixty-eight full term infants were successfully enrolled in this trial. Cardiac output (CO) and other hemodynamic parameters were evaluated in this study by EC device. Hemoglobin, glucose, and bilirubin concentrations were measured at 24 hours. Newborn infants were assigned randomly into group 1: DCC at 30 seconds, and group 2: DCC at 120 seconds, based on the time of cord clamping.

RESULTS

 Stroke volume (SV) (mL) and CO (L/min) were significantly higher in group 2 compared with group 1 at 5 minutes (6.71 vs. 5.35 and 1.09 vs. 0.75), 10 minutes (6.43 vs. 5.59 and 0.88 vs. 0.77), 15 minutes (6.45 vs. 5.60 and 0.89 vs. 0.76), and 24 hours (6.67 vs. 5.75 and 0.91vs. 0.81), respectively. Index of contractility (ICON; units) was significantly increased in group 2 at 5 minutes compared with group1 (114.2 vs. 83.8). Hematocrit (%) and total bilirubin concentrations (mg/dL) at 24 hours were significantly increased in group 2 compared with group 1 (51.5 vs. 40.5 and 3.8 vs. 2.9, respectively).

CONCLUSION

 Stroke volume and cardiac output are significantly higher in neonates with DCC at 120 seconds compared with 30 seconds that continues for the first 24 hours.

KEY POINTS

· CO is significantly increased with DCC at 120 seconds.. · SV is significantly increased with DCC at 120 seconds.. · Such effects continued during the entire 24 hours of life in full-term infants..

Umbilical arterial lactate levels after normal vaginal and elective cesarean delivery: The role of a longer active second stage most significant in high levels after vaginal delivery

AIM

To evaluate umbilical arterial lactate concentrations after spontaneous vaginal delivery and after elective Cesarean delivery, and to study the simultaneous effects of maternal and obstetric variables in high lactate levels in vaginally delivered healthy term singletons.

METHODS

The birth register study included information about the umbilical artery lactate values and clinical perinatal data from 7723 women and their singleton newborns (7301 spontaneous vaginal and 422 elective cesareans) from Kuopio University Hospital, Finland. High lactate levels were evaluated more extensively among healthy term neonates (N = 6541), to evaluate high levels after normal vaginal labors.

RESULTS

The mean lactate level was significantly lower after elective cesarean compared to vaginal delivery (2.42 [0.94] vs. 3.56 [1.62] mmol/l; p < 0.0001). Consequently, the 90th percentile limit values were 3.60 and 5.80 mmol/L. Among healthy term newborns born vaginally, higher lactate values (≥5.80 mmol/L) were independently associated with a longer duration of the active second stage of labor (ORs 1.91-10.97) and duration of ruptured fetal membranes (ORs 1.36-2.46), higher gestational age at birth (ORs 1.41-1.86), null parity (OR 2.17), maternal infection (OR 1.81) and short maternal stature (OR 1.45). We report 90th/95th limits for umbilical arterial lactate values in relation to the various durations of labors for term newborns who are delivered by the vaginal route.

CONCLUSIONS

Even though the high umbilical lactate levels may indicate serious birth asphyxia, levels after vaginal birth reflect the physiological stress and subclinical transient asphyxia frequently seen in normal vaginal deliveries.

Women's preference for a vaginal birth in Brazilian private hospitals: effects of a quality improvement project

BACKGROUND

In 2015, a quality improvement project called "Adequate Childbirth Project" (PPA) was implemented in Brazilian private hospitals in order to reduce cesarean sections without clinical indication. The PPA is structured in four components, one of which is directed at women and families. The objective of this study is to evaluate the effects of PPA on women's preference for vaginal birth (VB) at the end of pregnancy.

METHODS

Evaluative research conducted in 12 private hospitals participating in the PPA. Interviews were carried out in the immediate postpartum period and medical record data were collected at hospital discharge. The implementation of PPA activities and women's preference for type of birth at the beginning and end of pregnancy were compared in women assisted in the PPA model of care and in the standard of care model, using a chi-square statistical test. To estimate the effect of PPA on women's preference for VB at the end of pregnancy, multiple logistic regression was performed with selection of variables using a causal diagram.

RESULTS

Four thousand seven hundred ninety-eight women were interviewed. The implementation of the planned activities of PPA was less than 50%, but were significantly more frequent among women assisted in the PPA model of care. Women in this group also showed a greater preference for VB at the beginning and end of pregnancy. The PPA showed an association with greater preference for VB at the end of pregnancy in primiparous (OR 2.54 95% CI 1.99-3.24) and multiparous women (OR 1.44 95% CI 0.97-2.12), although in multiparous this association was not significant. The main factor associated with the preference for VB at the end of pregnancy was the preference for this type of birth at the beginning of pregnancy, both in primiparous (OR 18.67 95% CI 14.22-24.50) and in multiparous women (OR 53.11 95% CI 37.31-75.60).

CONCLUSIONS

The PPA had a positive effect on women's preference for VB at the end of pregnancy. It is plausible that more intense effects are observed with the expansion of the implementation of the planned activities. Special attention should be given to information on the benefits of VB in early pregnancy.

Maternal performance after childbirth and its predictors: a cross sectional study

BACKGROUND AND OBJECTIVES

Birthing parents need to use specialized skills as the first caregiver of the newborn. Several factors may affect performance. Yet there is a paucity of research in this area, and evidence remains inconsistent. Consequently, this study aimed to determine maternal performance after childbirth and its predictors.

METHODS

This cross-sectional study was conducted with those (n = 450) who had given birth (< two months) and been referred for the vaccination of their newborn. The multi-stage sampling method was carried out from April 2022 to February 2023. Participants who met the inclusion criteria completed a demographic and obstetric information questionnaire, along with the childbirth experience 2 (CEQ2), Barkin maternal performance and maternal self-efficacy scales. Multiple linear regression was used to investigate the predictive effect of the independent variables of childbirth experience, maternal self-efficacy, demographic and obstetric variables on the dependent variable of maternal performance.

RESULTS

The mean age of the participants was 26.78 and the mean total score of maternal performance was 91.04 (0-120). The highest and lowest scores related to the 'maternal competence' and the 'maternal needs' domains, with mean score calculated at 77.51 and 72.81 respectively. 'Childbirth experience' and 'maternal self-efficacy' domains had a statistically significant relationship with maternal performance (P < 0.05). Among the predictive factors of maternal performance, the results of our linear regression demonstrated the variables of birth experience (B = 0.63), maternal self-efficacy (B = 1.53), spouse's employment status (B = 5.78 for worker level, B = 3.99 for employee level), the number of previous childbirth experiences (B = -8.46), frequency of receiving antenatal care (B = -6.68), length of stay in the birth suite (B = -2.22) and length of stay in the hospital (B = 2.84) remained in the model. 53.2% of changes in maternal performance can be explained by these independent variables.

CONCLUSION

The promotion of evidence-based, person-centered, and respectful perinatal care during pregnancy and childbirth are of paramount importance. Strategies to improve the experience of childbirth and self-efficacy are especially required to improve maternal performance in the postpartum period. Prenatal care aimed at improving maternal function after childbirth will be important in achieving this overall.

Neonatal birth trauma and associated factors in low and middle-income countries: A systematic review and meta-analysis

Neonatal birth trauma, although it has steadily decreased in industrialized nations, constitutes a significant health burden in low-resource settings. Keeping with this, we sought to determine the pooled cumulative incidence (incidence proportion) of birth trauma and identify potential contributing factors in low and middle-income countries. Besides, we aimed to describe the temporal trend, clinical pattern, and immediate adverse neonatal outcomes of birth trauma. We searched articles published in the English language in the Excerpta Medica database, PubMed, Web of Science, Google, African Journals Online, Google Scholar, Scopus, and in the reference list of retrieved articles. Literature search strategies were developed using medical subject headings and text words related to the outcomes of the study. The Joana Briggs Institute quality assessment tool was employed and articles with appraisal scores of seven or more were deemed suitable to be included in the meta-analysis. Data were analyzed using the random-effect Dersimonian-Laird model. The full search identified a total of 827 articles about neonatal birth trauma. Of these, 37 articles involving 365,547 participants met the inclusion criteria. The weighted pooled cumulative incidence of birth trauma was estimated at 34 per 1,000 live births (95% confidence interval (CI) 30.5 to 38.5) with the highest incidence observed in Africa at 52.9 per 1,000 live births (95% CI 46.5 to 59.4). Being born to a mother from rural areas (odds ratio (OR), 1.61; 95% CI1.18 to 2.21); prolonged labor (OR, 5.45; 95% CI 2.30, 9.91); fetal malpresentation at delivery (OR, 4.70; 95% CI1.75 to 12.26); shoulder dystocia (OR, 6.11; 95% CI3.84 to 9.74); operative vaginal delivery (assisted vacuum or forceps extraction) (OR, 3.19; 95% CI 1.92 to 5.31); and macrosomia (OR, 5.06; 95% CI 2.76 to 9.29) were factors associated with neonatal birth trauma. In conclusion, we found a considerably high incidence proportion of neonatal birth trauma in low and middle-income countries. Therefore, early identification of risk factors and prompt decisions on the mode of delivery can potentially contribute to the decreased magnitude and impacts of neonatal birth trauma and promote the newborn's health.

Obstetric Interventions Among Native and Migrant Women: The (Over)use of Episiotomy in Portugal

Objective: Episiotomy, defined as the incision of the perineum to enlarge the vaginal opening during childbirth, is one of the most commonly performed surgical interventions in the world. We aimed to determine if migrant status is associated with episiotomy, and if individual characteristics mediate this association. Methods: We analyzed data from the Bambino study, a national, prospective cohort of migrant and native women giving birth at a public hospital in mainland Portugal between 2017 and 2019. We included all women with vaginal delivery. The association between migrant status and episiotomy was assessed using multivariable multilevel random-effect logistic regression models. We used path analysis to quantify the direct, indirect and total effects of migrant status on episiotomy. Results: Among 3,583 women with spontaneous delivery, migrant parturients had decreased odds of episiotomy, especially those born in Africa, compared to native Portuguese women. Conversely, with instrumental delivery, migrant women had higher odds of episiotomy. Disparities in episiotomy were largely explained by maternity units' factors, and little by maternal and fetal characteristics. Conclusion: Our results suggest non-medically justified differential episiotomy use during childbirth and highlight the importance of developing evidence-based recommendations for episiotomy use in a country with a high frequency of medical interventions during delivery.

Validity and reliability of the Greek version of Wijma delivery expectancy/experience questionnaire (Version A) among low-risk pregnant women

BACKGROUND

Fear of childbirth is a frequent health issue for pregnant women. The Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) is a widely used instrument to measure the fear of childbirth during the antenatal period. The aim of the study was to assess the psychometric properties of the W-DEQ (version A) in a sample of Greek pregnant women.

METHODS

Low-risk pregnant women in the second or third trimester of pregnancy (N = 201) were invited to participate in the study and to complete a booklet of questionnaires including the Greek versions of W-DEQ-A, State-Trait Anxiety Inventory (STAI), Coping Orientations to Problems Experienced (Brief COPE), Perceived Stress Scale (PSS-10) and Edinburgh Postnatal Depression Scale (EPDS). Exploratory (EFA) and confirmatory factor analysis (CFA) was performed.

RESULTS

The mean age of participants was 34.2 years (SD = 4.3 years). EFA yielded six factors ("Lack of self-efficacy", "Lack of positive anticipation", "Lack of feeling lonely", "Concerns about delivery and losing control", "Calmness", and "Concern for the child") of 33 items of W-DEQ-A. CFA confirmed the multidimensionality of the instrument. All Cronbach's alpha were over 0.7, indicating acceptable reliability of the factors. All factors were significantly correlated with each other, and convergent validity was demonstrated by a significant association with stress, anxiety, and depression among low-risk pregnant women.

CONCLUSION

The Greek version of W-DEQ-A proved to be a valid and reliable instrument of fear of childbirth among Greek low-risk pregnant women.