Evaluation of capacity to deliver emergency obstetrics and newborn care updated midwifery and reproductive health training curricula in Kenya: Before and after study

Provision of emergency obstetric and newborn care (EmONC) by skilled health personnel reduces maternal and newborn mortality. Pre-service diploma midwifery and clinical medicine (reproductive health) curricula in Kenya were reviewed and updated integrating the competency based EmONC curriculum. A two-part (virtual for theoretical component and face-to-face for the skills-based component) capacity building workshop for national midwifery/clinical medicine trainers of trainers to improve their capacity to implement the updated curricula and cascade it to colleagues nationwide was conducted.

This paper measured change in confidence of pre-service midwifery/clinical medicine educators to deliver the updated competency-based curricula in Kenya.

A before-after study among 51 midwifery/clinical medicine educators from 35 training colleges who participated in upskilling workshops as trainers-of-trainers for the updated curricula between September-November 2020. Assessment included self-reported confidence using a 3-point Likert scale (not confident, somewhat confident or extremely confident) in facilitating online teaching (as COVID-19 pandemic containment measure), EmONC skills teaching/demonstration; scenario/simulation teaching, small group discussions, peer review and giving effective feedback. Analysis involved test of proportions with p-values < 0.05 statistically significant. Results Educators’ confidence significantly improved in facilitating virtual teaching (46% to 70%, p = 0.0082). On the competency-based training, the confidence among educators significantly increased in facilitating EmONC skills teaching/demonstration (44% to 96%), facilitating scenario/simulation teaching (46% to 92%), facilitating small group discussions (46% to 94%), giving effective feedback (46% to 92%), and peer review and feedback (47% to 77%), p < 0.05). Conclusion The blended training improved the confidence of pre-service educators to deliver the updated midwifery/clinical medicine curricula.

Interpregnancy interval after a miscarriage and obstetric outcomes in the subsequent pregnancy in a low-income setting, Nigeria: A cohort study

The aim of this study was to determine and compare the occurrence of adverse pregnancy outcomes in a cohort of pregnant women with interpregnancy interval of  0.05). There was no increased risk of occurrence of adverse foetomaternal outcomes in both groups (p > 0.05). Multivariate logistic regression analysis showed that there was no statistical difference in the occurrence adverse foetomaternal outcomes between the studied cohorts (p > 0.05).

There was no significant difference in the occurrence of adverse maternal and foetal outcomes in the cohorts of mothers with short and normal interpregnancy interval following miscarriages in their last previous pregnancies

Postoperative outcomes associated with surgical care for women in Africa: an international risk-adjusted analysis

There is an increasing call for a broader approach to women’s surgical care in low- and middle-income countries, beyond access to caesarean section. While obstetric outcomes in Africa are well described, outcomes following non-obstetric surgical care for women in Africa are relatively unknown. Methods We did a secondary analysis of the African Surgical Outcomes Study (ASOS) focusing on severe postoperative complications (defined as death and severe complications) in females following non-obstetric, non-gynaecological surgical procedures. ASOS was a seven-day, African multi-centre prospective observational cohort study of adult (≥18 years) patients undergoing surgery in 25 African countries. These African outcomes were compared to international outcomes from the International Surgical Outcomes Study (ISOS) in a riskadjusted logistic regression analysis. Findings There were 1498 African participants and 18449 international participants who met the inclusion criteria. The African cohort were younger than the international cohort (47 (17) years versus 57 (17); p= <0·0001) and had a lower preoperative risk profile. Severe complications occurred in 41 (2·8%) of 1471 patients of the African cohort, and 431 (2·3%) of 18449 patients in the ISOS cohort, with in-hospital mortality following severe complications of 20/41 (48·8%) in ASOS and 78/431 (18·1%) in ISOS. The adjusted odds ratio for a woman in Africa developing a severe postoperative complication following elective non-obstetric, non-gynaecological surgery compared to the international incidence was 2·114 (95% CI 1·468 – 3·042, p<0·0001). Interpretation: Women living in Africa have double the odds of severe postoperative complications following elective non-obstetric, non-gynaecological surgery compared to the international incidence.

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

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.

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.

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.

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

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.

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.

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).

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

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.

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.

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.

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

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).

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.

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.

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

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.

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.

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.

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