A global study of the association of cesarean rate and the role of socioeconomic status in neonatal mortality rate in the current century

Introduction
Caesarean section (C/S) rates have significantly increased across the world over the past decades. In the present population-based study, we sought to evaluate the association between C/S and neonatal mortality rates.

Material and methods
This retrospective ecological study included longitudinal data of 166 countries from 2000 to 2015. We evaluated the association between C/S rates and neonatal mortality rate (NMR), adjusting for total fertility rate, human development index (HDI), gross domestic product (GDP) percentage, and maternal age at first childbearing. The examinations were also performed considering different geographical regions as well as regions with different income levels.

Results
The C/S rate and NMR in the 166 included countries were 19.97% ± 10.56% and 10 ± 10.27 per 1000 live birth, respectively. After adjustment for confounding variables, C/S rate and NMR were found correlated (r = -1.1, p < 0.001). Examination of the relationship between C/S rate and NMR in each WHO region resulted in an inverse correlation in Africa (r = -0.75, p = 0.005), Europe (r = -0.12, p < 0.001), South-East Asia (r = -0.41, p = 0.01), and Western Pacific (r = -0.13, p = 0.02), a direct correlation in America (r = 0.06, p = 0.04), and no correlation in Eastern Mediterranean (r = 0.01, p = 0.88). Meanwhile, C/S rate and NMR were inversely associated in regions with upper-middle (r = -0.15, p < 0.001) and lower-middle (r = -0.24, p < 0.001) income levels, directly associated in high-income regions (r = 0.02, p = 0.001), and not associated in low-income regions (p = 0.13). In countries with HDI below the centralized value of 1 (the real value of 0.9), the correlation between C/S rate and NMR was negative while it was found positive in countries with HDI higher than the mentioned cut-off.

Conclusions
This study indicated that NMR associated with C/S is dependent on various socioeconomic factors such as total fertility rate, HDI, GDP percentage, and maternal age at first childbearing. Further attentions to the socioeconomic status are warranted to minimize the NMR by modifying the C/S rate to the optimum cut-off.

The Risk Factors and Incidence of Perineal Tears among Pregnant Women

Aim: To determine the risk factors and prevalence of perineal tear in low-risk pregnant females.

Study Design: A retrospective cross-sectional study.

Place and Duration: In the Obstetrics and Gynecology department of Khawaja Muhammad Safdar Medical College, Allama Iqbal Memorial Teaching Hospital Sialkot for one-year duration from January 2020 to December 2020.

Methods: The females with perineal tear after birth included in this study. A total of 400 females were selected for this study. Results are articulated as adjusted odds ratio (OR) and ​​<0.05 of P value is considered significant.

Results: 400 total females had singleton vaginal delivery and perineal tears were noticed in 140 females. The episiotomy frequency for the total of 1st and 2nd degree, and 3rd and 4th degree (OASI) were 16.3%, 25%, and 1.5%, correspondingly. The perineal tear risk-factors are young mothers (teenagers OR = 5.6, 21-25 years OR = 4.3), primiparous women (OR = 12.6), gestational age less than 32 weeks OR = 0.175), received antenatal care (OR = 0.42), correspondingly. Primiparous females were 12.4 times more probable to have an episiotomy (OR = 12.4, 95% CI, 1.48-104.8, p = 0.02). A birth weight between 2.5-3.0 kgs and less than 2.5 kg (OR = 0.012 and 0.084, respectively) protects against Obstetric Anal Sphincter Injury.

Conclusions: The perineal injuries risk factors are comparable to those formerly described in other researches. There is an urgent need to train the gynae staff and doctors in proper selection for episiotomy and better perineal care in order to improve obstetric services in the Gynecology department. Identifying those at danger can decrease obstetric perineal injuries.

Admission Criteria of Obstetric Patients in Selected Intensive Care Units, Khartoum State, Sudan (2022)

The Obstetric admissions to the intensive care unit (ICU) require special care and attention by a multidisciplinary team. Pregnancy is associated with many maternal physiological and organ changes. These changes are primarily due to production of progesterone by the corpus luteum in early pregnancy and the placenta from ten weeks. They are admitted to the ICU for close observation to detect the problems earlier, perform invasive monitoring, increase nursing care or ventilatory support or any intervention that is not available at the wards. The aim of this study was to identify the admission criteria of obstetric patients. A retrospective study was conducted in maternal hospitals, from January to December 2021.70 patients with inclusion criteria were included. The results revealed that most of the patients diagnosed with Preeclampsia25.7%, eclampsia 22.9%, not applicable for the scoring system. Data was collected using a questionnaire filled by researchers from patients’files. The study found that most common cases were admitted to ICU with pre-eclampsia, eclampsia and postpartum hemorrhage, the antenatal care was low, that wasn’t applicable to scoring systems at admission and most patients did not need invasive procedures or mechanical ventilation.

Directly observed and reported respectful maternity care received during childbirth in public health facilities, Ibadan Metropolis, Nigeria

Respectful maternity care (RMC) is believed to improve women’s childbirth experience and increase health facility delivery. Unfortunately, few women in low- and middle-income countries experience RMC. Patient surveys and independent observations have been used to evaluate RMC, though seldom together. In this study, we assessed RMC received by women using two methodologies and evaluated the associated factors of RMC received. This was a cross-sectional study conducted in nine public health facilities in Ibadan, a large metropolis in Nigeria. We selected 269 pregnant women by cluster sampling. External clinical observers observed them during childbirth using the 29-item Maternal and Child Health Integrated Program RMC observational checklist. The same women were interviewed postpartum using the 15-item RMC scale for self-reported RMC. We analysed total RMC scores and RMC sub-category scores for each tool. All scores were converted to a percentage of the maximum possible to facilitate comparison. Correlation and agreement between the observed and reported RMC scores were determined using Pearson’s correlation and Bland-Altman analysis respectively. Multiple linear regression was used to identify factors associated with observed RMC. No woman received 100% of the observed RMC items. Self-reported RMC scores were much higher than those observed. The two measures were weakly positively correlated (rho = 0.164, 95%CI: 0.045–0.278, p = 0.007), but had poor agreement. The lowest scoring sub-categories of observed RMC were information and consent (14.0%), then privacy (28.0%). Twenty-eight percent of women (95%CI: 23.0% -33.0%) were observed to be hit during labour and only 8.2% (95%CI: 4.0%-18.0%) received pain relief. Equitable care was the highest sub-category for both observed and reported RMC. Being employed and having completed post-secondary education were significantly associated with higher observed RMC scores. There were also significant facility differences in observed RMC. In conclusion, the women reported higher levels of RMC than were observed indicating that these two methodologies to evaluate RMC give very different results. More consensus and standardisation are required in determining the cut-offs to quantify the proportion of women receiving RMC. The low levels of RMC observed in the study require attention, and it is important to ensure that women are treated equitably, irrespective of personal characteristics or facility context.

Abortion decision-making process trajectories and determinants in low- and middle-income countries: A mixed-methods systematic review and meta-analysis

Background
About 45.1% of all induced abortions are unsafe and 97% of these occur in low- and middle-income countries (LMICs). Women’s abortion decisions may be complex and are influenced by various factors. We aimed to delineate women’s abortion decision-making trajectories and their determinants in LMICs.

Methods
We searched Medline, EMBASE, PsychInfo, Global Health, Web of Science, Scopus, IBSS, CINAHL, WHO Global Index Medicus, the Cochrane Library, WHO website, ProQuest, and Google Scholar for primary studies and reports published between January 1, 2000, and February 16, 2021 (updated on June 06, 2022), on induced abortion decision-making trajectories and/or their determinants in LMICs. We excluded studies on spontaneous abortion. Two independent reviewers extracted and assessed quality of each paper. We used “best fit” framework synthesis to synthesise abortion decision-making trajectories and thematic synthesis to synthesise their determinants. We analysed quantitative findings using random effects model. The study protocol is registered with PROSPERO number CRD42021224719.

Findings
Of the 6960 articles identified, we included 79 in the systematic review and 14 in the meta-analysis. We identified nine abortion decision-making trajectories: pregnancy awareness, self-reflection, initial abortion decision, disclosure and seeking support, negotiations, final decision, access and information, abortion procedure, and post-abortion experience and care. Determinants of trajectories included three major themes of autonomy in decision-making, access and choice. A meta-analysis of data from 7737 women showed that the proportion of the overall women’s involvement in abortion decision-making was 0.86 (95% CI:0.73–0.95, I2 = 99.5%) and overall partner involvement was 0.48 (95% CI:0.29–0.68, I2 = 99.6%).

Interpretation
Policies and strategies should address women’s perceptions of safe abortion socially, legally, and economically, and where appropriate, involvement of male partners in abortion decision-making processes to facilitate safe abortion. Clinical heterogeneity, in which various studies defined “the final decision-maker” differentially, was a limitation of our study.

Funding
Nuffield Department of Population Health DPhil Scholarship for PL, University of Oxford, and the Medical Research Council Career Development Award for MN (Grant Ref: MR/P022030/1).

A Novel Approach in Management of Placenta Accreta Spectrum Disorders: A Single-Center Surgical Experience From Vietnam

Background: Placenta accreta spectrum disorder (PASD) is the leading cause which results in highly maternal mortality during pregnancy. Although hysterectomy has been the gold standard for PASD, recent data, together with our experience, suggest that conservative management might be better; and thus, we here attempted to determine this.

Methods: A retrospective observational study enrolled 65 patients at the Tu Du Hospital in Vietnam between January 2017 and December 2018. This study included all pregnant women above 28 weeks of gestational age, who had undergone cesarean delivery due to PASD diagnosed preoperatively by ultrasound or upon laparotomy. Additionally, all patients who desired uterine preservation underwent uterine conservative surgery, avoiding hysterectomy.

Results: Overall, the rate of successful preservation was 93.8%. Other main parameters evaluated included average operative blood loss of 987 mL, mean blood transfusion of 831 ± 672 mL; mean operative time of 135 ± 31 min, and average postoperative time of 5.79 days. Postoperative complications happened in six out of 65 cases due to intraoperative bleeding and postoperative infection, requiring peripartum hysterectomy in four patients.

Conclusions: Uterine conservative surgery was associated with less operative blood loss and blood transfusion amount. Its success rate of preservative method was approximately 94% in our study. Thus, this method can be acceptable in PASD management. Further studies might be necessary to evaluate the long-term effects of this method in PASD management

The causes of preterm neonatal deaths in India and Pakistan (PURPOSe): a prospective cohort study

Background
Preterm birth remains the major cause of neonatal death worldwide. South Asia contributes disproportionately to deaths among preterm births worldwide, yet few population-based studies have assessed the underlying causes of deaths. Novel evaluations, including histological and bacteriological assessments of placental and fetal tissues, facilitate more precise determination of the underlying causes of preterm deaths. We sought to assess underlying and contributing causes of preterm neonatal deaths in India and Pakistan.

Methods
The project to understand and research preterm pregnancy outcomes and stillbirths in South Asia (PURPOSe) was a prospective cohort study done in three hospitals in Davangere, India, and two hospitals in Karachi, Pakistan. All pregnant females older than 14 years were screened at the time of presentation for delivery, and those with an expected or known preterm birth, defined as less than 37 weeks of gestation, were enrolled. Liveborn neonates with a weight of 1000 g or more who died by 28 days after birth were included in analyses. Placentas were collected and histologically evaluated. In addition, among all neonatal deaths, with consent, minimally invasive tissue sampling was performed for histological analyses. PCR testing was performed to assess microbial pathogens in the placental, blood, and fetal tissues collected. An independent panel reviewed available data, including clinical description of the case and all clinical maternal, fetal, and placental findings, and results of PCR bacteriological investigation and minimally invasive tissue sampling histology, from all eligible preterm neonates to determine the primary and contributing maternal, placental, and neonatal causes of death.

Findings
Between July 1, 2018, and March 26, 2020, of the 3470 preterm neonates enrolled, 804 (23%) died by 28 days after birth, and, of those, 615 were eligible and had their cases reviewed by the panel. Primary maternal causes of neonatal death were hypertensive disease (204 [33%] of 615 cases), followed by maternal complication of pregnancy (76 [12%]) and preterm labour (76 [11%]), whereas the primary placental causes were maternal and fetal vascular malperfusion (172 [28%] of 615) and chorioamnionitis, funisitis, or both (149 [26%]). The primary neonatal cause of death was intrauterine hypoxia (212 [34%] of 615) followed by congenital infections (126 [20%]), neonatal infections (122 [20%]), and respiratory distress syndrome (126 [20%]).

Interpretation
In south Asia, intrauterine hypoxia and congenital infections were the major causes of neonatal death among preterm babies. Maternal hypertensive disorders and placental disorders, especially maternal and fetal vascular malperfusion and placental abruption, substantially contributed to these deaths.

Funding
Bill & Melinda Gates Foundation.

Effect of a model based on education and teleassistance for the management of obstetric emergencies in 10 rural populations from Colombia

Introduction: Pregnant women and health providers in rural areas of low-income and middle-income countries face multiple problems concerning high-quality obstetric care. This study was performed to identify changes in maternal and perinatal indicators after implementing a model based on education and telecare between a high-complexity hospital in 10 low-complexity hospitals in a southwestern region of Colombia.
Methods: A quasiexperimental study with a historic control group and without a pretest was conducted between 2017 and 2019 to make comparisons before and after obstetric emergency care through the use of teleassistance from 10 primary care centers to the referral center (Fundación Valle del Lili, FVL).
Results: A total of 470 patients were treated before teleassistance implementation and 154 patients were treated after teleassistance implementation. After program implementation, the maternal clinical indicators showed a 65% reduction in the number of obstetric patients who were referred with obstetric emergencies. The severity of maternal disease that was measured at the time of admission to level IV through the Modified Early Obstetric Warning System score was observed to decrease.
Conclusion: The implementation of a model based on education and teleassistance between low-complexity hospitals and tertiary care centers generated changes in indicators that reflect greater access to rural areas, lower morbidity at the time of admission, and a decrease in the total number of emergency events.

Use of antenatal and delivery care services and their association with maternal and infant mortality in rural India

Optimum use of antenatal care (ANC) and delivery care services could reduce morbidity and mortality among prospective mothers and their children. However, the role of ANC and delivery services in prevention of both maternal and child mortality is poorly understood, primarily because of dearth of prospective cohort data. Using a ten-years population-based prospective cohort data, this study examined the use of ANC and delivery services and their association with maternal and infant mortality in rural India. Descriptive statistics were estimated, and multivariable logistic regression modelling was used to attain the study objective. Findings revealed that consumption of ≥ 100 iron-and-folic acid (IFA) tablet/equivalent syrup during pregnancy had a protective association with maternal and infant mortality. Lack of maternal blood group checks during pregnancy was associated with increased odds of the death of infants. Caesarean/forceps delivery and delivery conducted by untrained personnel were associated with increased odds of maternal mortality. Findings from this study reemphasizes on increasing coverage and consumption of IFA tablets/equivalent syrup. Improved ANC and delivery services and increased uptake of all types of ANC and delivery care services are equally important for improvement in maternal and child survival in rural India.

Mistreatment of women during childbirth and its influencing factors in maternity hospitals in Tehran, Iran: a formative qualitative multi-stakeholder study

Background
Mistreatment during labour and childbirth is a common experience for many women around the world. A picture of the nature and types of mistreatment; and especially its influencing factors has not yet been identified in Iran. This study aimed to explore the manifestations of mistreatment and its influencing factors in maternity hospitals in Tehran.

Methods
A formative qualitative study was conducted using in-depth face-to-face interviews between October 2021 and May 2022 in five public hospitals. Participants included women, maternity healthcare providers, and managers at hospital and Ministry of Health levels. Participants were selected using purposive sampling. Recorded interviews were transcribed verbatim and thematically analyzed with a combined deductive and inductive approach using MAXQDA 18.

Results
A total of 60 interviews were conducted. Women experienced various forms of mistreatment during labour and childbirth, including verbal abuse, frequent and painful vaginal examinations, neglect and abandonment, lack of supportive care, denial of mobility and pain relief, and physical abuse. Four main themes were identified as the drivers of mistreatment: (1) individual-level factors (healthcare providers perception about women’s limited knowledge on childbirth process, untrained companions, mismatched expectations of women for care, and discrimination based on ethnicity or low socioeconomic status); (2) healthcare provider-level factors (healthcare provider stress/stressful working conditions, healthcare providers with limited personal experience of pregnancy and childbirth, neglect of midwives’ identities by doctors, poor educational contents and curriculum, and low salary and lack of incentive); (3) hospital-level factors (lack of staff, lack of supervision and control, type of hospital, inadequate physical structures); and (4) national health system-level factors (lack of access to pain management during labour and childbirth and perceptions about forced vaginal birth in public hospitals).

Conclusions
There are multiple level drivers for mistreatment which requires multifaceted interventions. These interventions should emphasize training of pregnant women and their companions, training healthcare providers, encouraging and managing work shifts, strengthening the position of midwives in public hospitals. Moreover, continuous monitoring of the performance of providers, increase staff numbers and improvement of physical space of the maternity wards, as well as implementation of the related guidelines, including painless childbirth, should also be considered.