Development of a clinical prediction model for perinatal deaths in low resource settings

BACKGROUND

Most pregnancy-related deaths in low and middle income countries occur around the time of birth and are avoidable with timely care. This study aimed to develop a prognostic model to identify women at risk of intrapartum-related perinatal deaths in low-resourced settings, by (1) external validation of an existing prediction model, and subsequently (2) development of a novel model.

METHODS

A prospective cohort study was conducted among pregnant women who presented consecutively for delivery at the maternity unit of Zanzibar's tertiary hospital, Mnazi Mmoja Hospital, the Republic of Tanzania between October 2017 and May 2018. Candidate predictors of perinatal deaths included maternal and foetal characteristics obtained from routine history and physical examination at the time of admission to the labour ward. The outcomes were intrapartum stillbirths and neonatal death before hospital discharge. An existing stillbirth prediction model with six predictors from Nigeria was applied to the Zanzibar cohort to assess its discrimination and calibration performance. Subsequently, a new prediction model was developed using multivariable logistic regression. Model performance was evaluated through internal validation and corrected for overfitting using bootstrapping methods.

FINDINGS

5747 mother-baby pairs were analysed. The existing model showed poor discrimination performance (c-statistic 0·57). The new model included 15 clinical predictors and showed promising discriminative and calibration performance after internal validation (optimism adjusted c-statistic of 0·78, optimism adjusted calibration slope =0·94).

INTERPRETATION

The new model consisted of predictors easily obtained through history-taking and physical examination at the time of admission to the labour ward. It had good performance in predicting risk of perinatal death in women admitted in labour wards. Therefore, it has the potential to assist skilled birth attendance to triage women for appropriate management during labour. Before routine implementation, external validation and usefulness should be determined in future studies.

FUNDING

The study received funding from Laerdal Foundation, Otto Kranendonk Fund and UMC Global Health Fellowship. TD acknowledges financial support from the Netherlands Organisation for Health Research and Development (grant 91617050).

Quality improvement: A practical nursing program's admission test

INTRODUCTION

Academic institutions are under pressure to maintain a nearly flawless retention rate, while graduating successful students. The use of standardized admission tests to provide data driven decisions regarding applicant selection is common. The varying reliability and validity of current standardized tests inspired a large Canadian academic institution to use a faculty developed admission test for admission to its practical nursing (PN) program.

METHODS

The target population for this project was a purposive, convenience sample of graduated PN students from a large publically funded polytechnic institution in southern Ontario, Canada, who had completed the Canadian Practical Nurse Registration Examination (CPNRE) within 2014-2016 (n = 293). Data was obtained retrospectively, and included program entry grade-point average (GPA) and CPNRE result, as well as chemistry, English, biology, and math admission test scores.

RESULTS

The predictors of chemistry, English, math admission test scores, and program entry GPA did not have an effect beyond the effects of the model's predictors. In this model, the R² suggests that 9% of the variance can be explained, and 91% not explained. In consideration of all independent variables, findings indicate that mean biology admission test scores (M =74.96) are a predictor of student CPNRE success. Additionally, students who pass the CPNRE have a higher program GPA.

CONCLUSIONS

Academic factors including program entry GPA, English, math, biology and chemistry admission scores are a fragment of the characteristics to be considered when determining the predictability of success in PN students. Therefore, it is imperative that program admission processes identify and measure nonacademic program entry criteria, as academic criterion have limited predictability. Furthermore, in isolation, academic admission criteria could be used to identify at-risk-students for appropriate remediation/counselling or as a placement test.

Delphi consensus statement on intrapartum fetal monitoring in low-resource settings

Objective

To determine acceptable and achievable strategies of intrapartum fetal monitoring in busy low‐resource settings.

Methods

Three rounds of online Delphi surveys were conducted between January 1 and October 31, 2017. International experts with experience in low‐resource settings scored the importance of intrapartum fetal monitoring methods.

Results

71 experts completed all three rounds (28 midwives, 43 obstetricians). Consensus was reached on (1) need for an admission test, (2) handheld Doppler for intrapartum fetal monitoring, (3) intermittent auscultation (IA) every 30 minutes for low‐risk pregnancies during the first stage of labor and after every contraction for high‐risk pregnancies in the second stage, (4) contraction monitoring hourly for low‐risk pregnancies in the first stage, and (5) adjunctive tests. Consensus was not reached on frequency of IA or contraction monitoring for high‐risk women in the first stage or low‐risk women in the second stage of labor.

Conclusion

There is a gap between international recommendations and what is physically possible in many labor wards in low‐resource settings. Research on how to effectively implement the consensus on fetal assessment at admission and use of handheld Doppler during labor and delivery is crucial to support staff in achieving the best possible care in low‐resource settings.

International fetal monitoring strategies are not achievable in many low‐resource settings. Consensus was reached that admission assessment and Doppler are the first steps towards acceptable surveillance.

Admission Test and Pregnancy Outcome

BACKGROUND

The admission test (AT) has been carried out for many years, but there are still debates about the prognostic value of the test. Therefore, we aimed to examine the value of the AT in predicting the adverse outcome in neonates.

METHODS

In this cross-sectional study, 425 pregnant women with normal vaginal delivery were studied between2009 and 2014at Vali-e-Asr Hospital. Based on the results, the women were divided into 2groups of normal and abnormal ATs. All the patients were followed up until the birth of their baby, when the status of mother and neonate was determined. The main outcomes of the study were cesarean rate, neonatal intensive care unit (NICU) admission, fetus demise, neonatal acidosis, and Apgar score. The independent t-test, chi-square test, Fisher exact test, and logistic regression were used for statistical analysis. The data were analyzed using SPSS (version 17).

RESULTS

Of 425 pregnant women studied, 142 (33.4%) had abnormal ATs with a mean age of 29 (±4.5) years. Multivariate analysis showed that an abnormal AT was able to predict the incidence of cesarean section, intrauterine growth restriction, turned cord, and Apgar<7, but it could not predict neonatal death and hypoxia.

CONCLUSION

The AT was shown to be a useful screening test with risk factors such as oligohydramnios, bloody amniotic fluid, meconium amniotic fluid, intrauterine growth restriction, and turned cord. Additionally, the test was also able to predict NICU admission and the need for cesarean section, but it could not predict the occurrence of neonatal death.

Reliability of admission cardiotocography for intrapartum monitoring in low resource setting

Background

To evaluate the role of admission cardiotocography in intrapartum patients in detecting fetal hypoxia already present and to correlate the results of admission cardiotocography with perinatal outcome.

Materials and Methods:

It was a cross-sectional study conducted in the Labor and Maternity ward during the period 2007-2009. The study included 176 pregnant women (both high risk and low risk), admitted to the emergency department or through the outpatient department with period of gestation ≥36 weeks, in first stage of labor with fetus in cephalic presentation. All of them were subjected to an admission test, a 20 min recording of fetal heart rate and uterine contractions on cardiotocograph machine at the time of admission.

Results:

The results of the admission test were ‘reactive’ in 82.38%, ‘equivocal’ in 10.22%, and ‘ominous’ in 7.38% women. Women with the reactive admission test had low risk of intrapartum fetal distress (6.9%) as compared to 39.9% in the equivocal and 84.6% in the ominous group (P<0.001). Incidence of moderate to thick meconium stained liqor were more in ominous (61.5%) and equivocal group (33.3%) in compared to reactive group (4.8%) (P<0.001). Incidence of NICU admission was also significantly high (62%) in babies delivered from mother with ominous test group compared to those with equivocal (28%) and reactive test (3.45%) group babies. Neonatal mortality was also seen in babies born to mothers with equivocal (5.5%) and ominous (7.6%) admission test groups. Operative delivery for fetal distress was required in only 5.5% (8 of 145) woman of the reactive group, in 27.8% (5 of 18) woman of the equivocal group and in 84.6% (11 of 13) women of the ominous group.

Conclusion:

The admission cardiotocography is a simple non-invasive test that can serve as screening tool to detect fetal distress already present or likely to develop and prevent unnecessary delay in intervention. The test has high specificity and can help in ‘triaging’ fetuses in obstetric wards of developing countries with a heavy workload and limited resources.

Reliability of a science admission test (HAM-Nat) at Hamburg medical school

Objective: The University Hospital in Hamburg (UKE) started to develop a test of knowledge in natural sciences for admission to medical school in 2005 (Hamburger Auswahlverfahren für Medizinische Studiengänge, Naturwissenschaftsteil, HAM-Nat). This study is a step towards establishing the HAM-Nat. We are investigating

parallel forms reliability,

the effect of a crash course in chemistry on test results, and

correlations of HAM-Nat test results with a test of scientific reasoning (similar to a subtest of the "Test for Medical Studies", TMS).

Methods: 316 first-year students participated in the study in 2007. They completed different versions of the HAM-Nat test which consisted of items that had already been used (HN2006) and new items (HN2007). Four weeks later half of the participants were tested on the HN2007 version of the HAM-Nat again, while the other half completed the test of scientific reasoning. Within this four week interval students were offered a five day chemistry course.

Results: Parallel forms reliability for four different test versions ranged from r_tt=.53 to r_tt=.67. The retest reliabilities of the HN2007 halves were r_tt=.54 and r_tt =.61. Correlations of the two HAM-Nat versions with the test of scientific reasoning were r=.34 und r=.21. The crash course in chemistry had no effect on HAM-Nat scores.

Conclusions: The results suggest that further versions of the test of natural sciences will not easily conform to the standards of internal consistency, parallel-forms reliability and retest reliability. Much care has to be taken in order to assemble items which could be used interchangeably for the construction of new test versions. The test of scientific reasoning and the HAM-Nat are tapping different constructs. Participation in a chemistry course did not improve students’ achievement, probably because the content of the course was not coordinated with the test and many students lacked of motivation to do well in the second test.