Supporting midwifery is the answer to the wicked problems in maternity care

The film Don’t Look Up, examines what it will take to get world leaders and the public to be proactive about a comet that is on a collision course with earth. We argue that the same attitude of self-interested denialism is stopping crucial action being taken when it comes to supporting midwifery models of care to address the current problems in maternity care.
Although life-saving when indicated, medical interventions in childbirth can be harmful when overused.1 A challenge in striking the right balance is that the bar for benefit when it comes to birth outcomes has been set at immediate survival. This approach overlooks clinical complications, such as placenta praevia or accreta associated with caesarean, and fails to value the personal autonomy of women and communities. In global settings, caesarean section rates, which are often used as a proxy to understand the safety of a maternity system, have recently come under scrutiny. Inquiries into adverse outcomes in the Shrewsbury and Telford Hospital National Health Service Trust in the UK has led to sensational media reporting and concerns about the dangers of setting caesarean section targets. This reporting has led to a focus on individual decision makers rather than faulty systems. We know a bad system will beat the best health-care provider every time
The centrality of midwives in supporting the physiological process of giving birth is at the core of this debate. Midwives have been singled out for blame when it comes to poor outcomes, with little consideration given to the fragmented models of care they work in, where they do not always have professional autonomy and respectful collaboration. This attitude creates an environment of professional and philosophical conflict that does not put women’s optimal care and needs at the centre. Relational models of care such as continuity of midwifery care, which are supported by high-level evidence as being cost effective and leading to optimal outcomes,3 are ignored. Such models have the potential to save 4·3 million lives per year, but realising this opportunity requires a deeper understanding of why they are not reaching scale.
The way we treat women during pregnancy, childbirth, and postpartum, and the institutional options of care we provide them within health systems, directly reflect the way we value women in our societies. In too many settings we are ignoring the benefits of midwifery models of care, degrading the status of midwives, and removing financing from midwifery services and education, under the guise of safety that ignores physiology and women’s chances for optimal mental and physical health.
There is a shortage of approximately a third of the midwives we need globally, which is crucial considering that midwives who are educated and regulated to international standards of care can provide 87% of essential maternity care needs and would prevent 67% of maternal deaths, 64% of newborn deaths, and 65% of stillbirths.4 Midwifery provides a 16 times return on investment.3, 5 Evidence is mounting on how midwives improve maternity care globally; yet, midwives are leaving the profession—burned out, disillusioned, and under valued.6 The latest sensationalised media reporting in the UK has demoralised midwives even more, with global impacts. As a predominantly female profession, midwives continue to be marginalised, overworked, poorly paid, and do not have decision making authority in many countries.
The aim of intervening in the physiological processes of pregnancy and birth is to improve outcomes and safety for women and babies. Commonly used birth interventions such as caesarean sections and induction, which were previously used to treat obvious complications, are used more commonly for women that are unlikely to benefit from them, and can even cause harm to healthy women. These harms contribute to gender, racial, and geographical inequities, and there is growing concern regarding generational inequities. Less concern is afforded to women suffering from birth trauma, which is higher following intervention in birth, especially when women feel poorly informed and coerced into this.10
Although high-income countries (HICs) often drive the dominant discourse when it comes to maternity care, in some low-income and middle-income countries (LMICs) women cannot access a safe caesarean section even when it is needed, demonstrating significant inequalities in maternal care. Caesarean section rates have escalated in LMICs without adequate training or access to additional skills such as anaesthetics, leading to deadly outcomes; and maternal mortality rates are up to 100 times higher in LMICs than HICs. There is increased economic hardship for communities and stretched health systems, and distrust of hospital care and health-care providers.8 Women who become pregnant after caesarean section are at a higher risk of subsequent surgery, with inadequate attention given to additive morbidity over their reproductive life course.
The use of technology and interventions in childbirth scale up quickly and are difficult to de-implement, even when there is evidence of harm. Fiscal accountability and resource-intense care that contributes to the health-care carbon footprint (10% of the US total) should be key considerations.
To meet the 2030 Sustainable Development Goals and prevent an unfolding disaster, we call for urgent action and a united voice on the four main groups of action in the Midwifery 2030 Pathway (panel).

Pattern of contraceptive use among reproductive-aged women with diabetes and/or hypertension: findings from Bangladesh Demographic and Health Survey

Background
The prevalence of chronic conditions such as diabetes and hypertension is increasing among reproductive-aged women in Bangladesh. However, the pattern of contraceptive use among this population remains unknown. We, therefore, explored the pattern of contraceptive use among reproductive-aged women with diabetes and/or hypertension in Bangladesh.

Methods
We extracted and analysed data of 3,947 women from the 2017/18 Bangladesh Demographic and Health Survey. Women’s pattern of contraceptive use was our outcome variable. We first classified the contraceptive using status as no method use, traditional method use (periodic abstinence, withdrawal, other traditional) and modern method use (pill, intra-uterine device, injections, male condom, female sterilization, male sterilization). We later classified these as (i) no contraceptive use vs any contraceptive use, (ii) traditional method or no use vs modern method use, (iii) traditional method vs modern method use. The explanatory variables were diagnosis of diabetes only, hypertension only or both diabetes and hypertension. The multilevel Poisson regression with robust variance was used to explore the associations.

Results
The overall prevalence of contraceptive use was 68.0% (95% CI 66.3–69.7). The corresponding prevalences were 69.4% (95% CI 61.8–76.1) in women with diabetes only, 67.3% (95% CI 63.5–70.9) with hypertension only, and 62.0% (95% CI 52.8–70.4) in women having both diabetes and hypertension. The prevalence of modern methods of contraceptive use was lower (46.4%, 95% CI 37.4–55.6) and traditional methods use was higher (16.6%, 95% CI 13.8–16.8) in women who had both diabetes and hypertension than in women who did not have these conditions. The fully adjusted regression model showed that the prevalence of traditional method use was 31% (Prevalence ratio: 1.31, 95% CI 1.02–2.01) higher in women having both diabetes and hypertension compared with their counterparts who had none of these conditions.

Conclusion
In Bangladesh, women with both diabetes and hypertension were more likely to use traditional contraception methods. These women are likely to experience increased risks of unwanted pregnancies and associated adverse maternal and child health outcomes. Targeted policies and programs should be undertaken to promote modern contraceptive use among women living with both chronic conditions.

A study of clinical and economic burden of surgical site infection in patients undergoing caesarian section at a tertiary care teaching hospital in India

Background
Caesarian section is one of the most commonly performed surgeries in India. Determination of the incidence as well as the clinical and financial burden of post caesarian surgical site infection (SSI) is of critical importance for all the stakeholders for rational and fair allocation of resources.

Methods
This study was a prospective observational case-control study. The mean direct and indirect cost of treatment for the cases were compared with the control patients. An unpaired t-test was used to compare the mean between the two groups.

Results
Out of 2024 patients, who underwent caesarian section during the study period, 114 had acquired incisional surgical site infection (ISSI), with the infection incidence being 5.63%. The total cost of illness due to post caesarian ISSI was almost three times higher compared to the non-infected matched control group. (P<0.0001). An average length of hospital stay in the ISSI patient group was 10 days longer than that in the control group (P<0.0001) and importantly total length of antimicrobial therapy(LOT) in patients with ISSI was also almost three times higher than the control group (P<0.0001).

Conclusion
The development of post caesarian SSI imposes a significant clinical as well as a financial burden. The study highlights the necessity of taking effective preventive measures to decrease the incidence of SSI.

Exploring health care providers’ experiences of and perceptions towards the use of misoprostol for management of second trimester incomplete abortion in Central Uganda

Introduction
Women living in low- and middle-income countries still have limited access to quality second trimester post abortion care. We aim to explore health care providers’ experiences of and perceptions towards the use of misoprostol for management of second trimester incomplete abortion.

Methods
This qualitative study used the phenomenology approach. We conducted 48 in-depth interviews for doctors and midwives at 14 public health facilities in central Uganda using a flexible interview guide. We used inductive content analysis and made code frequencies based on health care provider cadre, and health facility level and then abstracted themes from categories.

Results
Well trained midwives were perceived as competent to manage second trimester post abortion care stable patients, however doctor’s supervision in case of complications was considered important. Sometimes, midwives were seen as offering better care than doctors given their stronger presence in the facilities. Misoprostol received unanimous support and viewed as: safe, effective, cheap, convenient, readily available, maintained patient privacy, and saved resources. Challenges faced included: side effects, prolonged hospital stay, treatment failure, inclination to surgical evacuation, heavy work load, inadequate space, lack of medical commodities, frequent staff rotations which affects the quality of patient care. To address these challenges, respondents coped by: giving patients psychological support, analgesics, close patient monitoring, staff mentorship, commitment to work, team work and patient involvement in care.

Conclusion
Misoprostol is perceived as an ideal uterine evacuation method for second trimester post abortion care of uncomplicated patients and trained midwives are considered competent managing these patients in a health facility setting with a back-up of a doctor. Health care providers require institutional and policy environment support for improved service delivery.

Sexual and Reproductive Health and Rights (SRHR) and Maternal, Neonatal and Child Health (MNCH) in Bangladesh: Impacts of the Covid-19 Pandemic

The Covid-19 pandemic has exacerbated and drawn fresh attention to long-standing systemic weaknesses in health and economic systems. The virus – and the public health response – has wrought significant disruption on sexual and reproductive health and rights (SRHR) and maternal, neonatal and child health (MNCH) in Bangladesh. Known negative health outcomes include increased domestic and gender-based violence, child marriage, negative mental health, and adverse child health outcomes. This scoping paper for the Covid-19 Learning, Evidence and Research Programme for Bangladesh (CLEAR) aims to inform future research and policy engagement to support response, recovery, progress, and future health system resilience for SRHR and MNCH in Bangladesh, following the Covid-19 crisis. We present what is known on disruptions and impacts, as well as evidence gaps and priority areas for future research and engagement.

Implementing the WHO Labour Care Guide to reduce the use of Caesarean section in four hospitals in India: protocol and statistical analysis plan for a pragmatic, stepped-wedge, cluster-randomized pilot trial

BACKGROUND
The World Health Organization (WHO) Labour Care Guide (LCG) is a paper-based labour monitoring tool designed to facilitate the implementation of WHO’s latest guidelines for effective, respectful care during labour and childbirth. Implementing the LCG into routine intrapartum care requires a strategy that improves healthcare provider practices during labour and childbirth. Such a strategy might optimize the use of Caesarean section (CS), along with potential benefits on the use of other obstetric interventions, maternal and perinatal health outcomes, and women’s experience of care. However, the effects of a strategy to implement the LCG have not been evaluated in a randomised trial. This study aims to: 1) develop and optimise a strategy for implementing the LCG (formative phase); and 2) To evaluate the implementation of the LCG strategy compared with usual care (trial phase).

METHODS
In the formative phase, we will co-design the LCG strategy with key stakeholders informed by facility assessments and provider surveys, which will be field tested in one hospital. The LCG strategy includes a LCG training program, ongoing supportive supervision from senior clinical staff, and audit and feedback using the Robson Classification. We will then conduct a stepped-wedge, cluster-randomized pilot trial in four public hospitals in India, to evaluate the effect of the LCG strategy intervention compared to usual care (simplified WHO partograph). The primary outcome is the CS rate in nulliparous women with singleton, term, cephalic pregnancies in spontaneous labour (Robson Group 1). Secondary outcomes include clinical and process of care outcomes, as well as women’s experience of care outcomes. We will also conduct a process evaluation during the trial, using standardized facility assessments, in-depth interviews and surveys with providers, audits of completed LCGs, labour ward observations and document reviews. An economic evaluation will consider implementation costs and cost-effectiveness.

DISCUSSION
Findings of this trial will guide clinicians, administrators and policymakers on how to effectively implement the LCG, and what (if any) effects the LCG strategy has on process of care, health and experience outcomes. The trial findings will inform the rollout of LCG internationally.

TRIAL REGISTRATION:
CTRI/2021/01/030695 (Protocol version 1.4, 25 April 2022)

Evolution of patterns of care for women with cervical cancer in Morocco over a decade

Background
We conducted a Pattern-of-care (POC) study at two premier-most public-funded oncology centers in Morocco to evaluate delays in care continuum and adherence to internationally accepted treatment guidelines of cervical cancer.

Method
Following a systematic sampling method, cervical cancer patients registered at Centre Mohammed VI (Casablanca) and Institut National d’Oncologie (Rabat) during 2 months of every year from 2008 to 2017, were included in this retrospective study. Relevant information was abstracted from the medical records.

Results
A total of 886 patients was included in the analysis; 59.5% were at stage I/II. No appreciable change in stage distribution was observed over time. Median access and treatment delays were 5.0 months and 2.3 months, respectively without any significant temporal change. Concurrent chemotherapy was administered to 57.7% of the patients receiving radiotherapy. Surgery was performed on 81.2 and 34.8% of stage I and II patients, respectively. A very high proportion (85.7%) of operated patients received post-operative radiation therapy. Median interval between surgery and initiation of radiotherapy was 3.1 months. Only 45.3% of the patients treated with external beam radiation received brachytherapy. Radiotherapy was completed within 10 weeks in 77.4% patients. An overall 5-year disease-free survival (DFS) was observed in 57.5% of the patients – ranging from 66.1% for stage I to 31.1% for stage IV. Addition of brachytherapy to radiation significantly improved survival at all stages. The study has the usual limitations of retrospective record-based studies, which is data incompleteness.

Conclusion
Delays in care continuum need to be further reduced. Increased use of chemoradiation and brachytherapy will improve survival further.

The role of telepathology in diagnosis of premalignant and malignant cervical lesions Implementation at a tertiary hospital in Northern Tanzania

Introduction
Adequate and timely access to pathology services is a key to scale up cancer control, however, there is an extremely shortage of pathologists in Tanzania. Telepathology (scanned images microscopy) has the potential to increase access to pathology services and it is increasingly being employed for primary diagnosis and consultation services. However, the experience with the use of telepathology in Tanzania is limited. We aimed to investigate the feasibility of using scanned images for primary diagnosis of pre-malignant and malignant cervical lesions by assessing its equivalency to conventional (glass slide) microscopy in Tanzania.

Methods
In this laboratory-based study, assessment of hematoxylin and eosin stained glass slides of 175 cervical biopsies were initially performed conventionally by three pathologists independently. The slides were scanned at x 40 and one to three months later, the scanned images were reviewed by the pathologists in blinded fashion. The agreement between initial and review diagnoses across participating pathologists was described and measured using Cohen’s kappa coefficient (κ).

Results
The overall concordance of diagnoses established on conventional microscopy compared to scanned images across three pathologists was 87.7%; κ = 0.54; CI (0.49–0.57).The overall agreement of diagnoses established by local pathologist on conventional microscopy compared to scanned images was 87.4%; κ = 0.73; CI (0.65–0.79). The concordance of diagnoses established by senior pathologist compared to local pathologist on conventional microscopy and scanned images was 96% and 97.7% respectively. The inter-observer agreement (κ) value were 0.93, CI (0.87–1.00) and 0.94, CI (0.88–1.00) for conventional microscopy and scanned images respectively.

Conclusions
All κ coefficients expressed good intra- and inter-observer agreement, suggesting that telepathology is sufficiently accurate for primary diagnosis in surgical pathology. The discrepancies in interpretation of pre-malignant lesions highlights the importance of p16 immunohistochemistry in definitive diagnosis in these lesions. Sustainability factors including hardware and internet connectivity are essential components to be considered before telepathology may be deemed suitable for widely use in Tanzania.

Safe caesarean sections in South Africa: Is internship training sufficient?

Background. In Africa, the maternal mortality rate after caesarean section (CS) is 50 times higher than that in high-income countries. In South Africa (SA), women who undergo CS have a three times higher mortality rate than those who deliver vaginally. Anaesthetic complications and obstetric haemorrhage are major drivers of poor outcomes, and the case fatality rate for CS at district hospitals is particularly high.
Objectives. To assess the adequacy of anaesthetic and obstetric internship training in preparing interns to perform CS independently and safely. Methods. This was an observational cross-sectional survey of all community service officers (CSOs) in KwaZulu-Natal (KZN), SA, in 2020. Data were collected via an electronic survey that comprised 68 questions in 4 domains, covering personal information, obstetric surgical training, obstetric anaesthetic training and support received as a CSO.

Results. Surveys were sent to 228 CSOs in KZN, with 160 responses received (70% response rate). Respondents included participants from 8 medical schools and 33 internship facilities across the country. One in 8 interns (n=21/160) did not perform the required 10 CSs. Supervision in theatre was provided by an obstetric specialist for at least 1 CS in n=57/160 (35.62%; 95% confidence interval (CI) 28.54 – 43.39) participants, and n=45/160 (28.13%; 95% CI 21.66 – 35.64) interns never performed an emergency CS. Interns had limited opportunity to be the primary surgeon for complicated cases. Only 1/5 interns performed >5 obstetric general anaesthetics.

Conclusions. This survey showed that there are deficiencies in the current CS-related training of interns in SA. A lack of exposure to adequate obstetric surgical training and obstetric general anaesthesia is likely to impact on the performance of CSOs and on the safety of the CS service provided at district hospitals. The content and quality of the CS-related intern training programme needs to be enhanced to improve the competence of CSOs. The Health Professions Council of South Africa (HPCSA)’s stipulations for internship training must be adhered to and should look to include simulation training, basic surgical skills courses and prioritisation of exposure to complicated surgical scenarios.

Effective interventions to ensure MCH (Maternal and Child Health) services during pandemic related health emergencies (Zika, Ebola, and COVID-19): A systematic review

Introduction
Ensuring accessible and quality health care for women and children is an existing challenge, which is further exacerbated during pandemics. There is a knowledge gap about the effect of pandemics on maternal, newborn, and child well-being. This systematic review was conducted to study maternal and child health (MCH) services utilization during pandemics (Zika, Ebola, and COVID-19) and the effectiveness of various interventions undertaken for ensuring utilization of MCH services.

Methodology
A systematic and comprehensive search was conducted in MEDLINE/PubMed, Cochrane CENTRAL, Embase, Epistemonikos, ScienceDirect, and Google Scholar. Of 5643 citations, 60 potential studies were finally included for analysis. The included studies were appraised using JBI Critical appraisal tools. Study selection and data extraction were done independently and in duplicate. Findings are presented narratively based on the RMNCHA framework by World Health Organization (WHO).

Results
Maternal and child health services such as antenatal care (ANC) visits, institutional deliveries, immunization uptake, were greatly affected during a pandemic situation. Innovative approaches in form of health care services through virtual consultation, patient triaging, developing dedicated COVID maternity centers and maternity schools were implemented in different places for ensuring continuity of MCH care during pandemics. None of the studies reported the effectiveness of these interventions during pandemic-related health emergencies.

Conclusion
The findings suggest that during pandemics, MCH care utilization often gets affected. Many innovative interventions were adopted to ensure MCH services. However, they lack evidence about their effectiveness. It is critically important to implement evidence-based appropriate interventions for better MCH care utilization.