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To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of [greater than or equal to]3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict [greater than or equal to]3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive [greater than or equal to]3 ANC visits (p < 0.001). Receiving, Author(s): Lisa M. Nathan[sup.1] , Quihu Shi[sup.2] , Kari Plewniak[sup.1] , Charles Zhang[sup.3] , Damien Nsabimana[sup.4] , Marc Sklar[sup.1] , Eugene Mutimura[sup.5] , Irwin R. Merkatz[sup.1] , Mark H. Einstein[sup.1] [...]

A number of debates exist in Africa, due to the HIV epidemics, on whether institutionalized compared with community-based care provide optimum management of infected children. Patterns of morbidity and mortality among HIV-1-infected children residing at an orphanage in Nairobi are characterized.

Abstract Obstetric hemorrhage is the leading cause of maternal morbidity and mortality in the world. Disparities in the prevalence of obstetric hemorrhage and its related mortality both on a global scale and locally in the United States indicate that a significant proportion is preventable. In many parts of the world, including the United States, there has also been an unexplainable increase in rates of postpartum hemorrhage. Efforts should focus on implementing comprehensive hemorrhage toolkit/bundles, which research has shown may have the potential to reduce severe maternal morbidity from hemorrhage. [ABSTRACT FROM AUTHOR]

Objective: To create, implement, and evaluate the effectiveness of a cesarean delivery checklist on maternal and neonatal outcomes in a rural African hospital. Methods: Based on input from local authorities, WHO's Safe Surgical Checklist was modified for cesarean delivery and adapted for use in low‐resource settings. Retrospective chart review between April and August 2013 in Kibogora Hospital, Nyamasheke, Rwanda, included the first 100 women undergoing cesarean after checklist implementation and the last 100 women undergoing cesarean before implementation. Checklist utilization was determined and degree of completeness assessed. Outcomes were compared between patients for whom the checklist was utilized and patients for whom the checklist was not utilized, in both pre and post‐implementation groups. Results: Checklist utilization rate was 83.0% (83/100). Checklist utilization was associated with significant increases in documentation of estimated blood loss (91.6% [76/83] vs 0.9% [1/117], P<0.001) and antibiotic administration before incision (96.4% [80/83] vs 30.8% [36/117], P<0.001). It was also associated with decreased rates of hospitalization longer than the standard 4 days (19.3% [16/83] vs 70.1% [82/117], P<0.001). Conclusion: Implementation of a cesarean delivery checklist via a culturally specific and resource‐specific strategy resulted in high utilization rates and improved performance in key best practices by healthcare providers. A cesarean delivery checklist that was adapted and implemented via a culturally specific and resource‐specific strategy improved performance in key best practices by healthcare providers. [ABSTRACT FROM AUTHOR]

Based on years of review and analysis of severe maternal morbidity and maternal mortality cases, it is clear that the high rates of maternal mortality in this country are due to more than obstetrical emergencies gone awry. Many nonmedical factors contribute to these poor outcomes including complex and ineffectual health care systems, poor coordination of care, and structural racism. In this article we discuss what physicians can and cannot accomplish on their own, the role of race and racism, and barriers built into the manner in which health care is delivered. We conclude that while obstetricians must continue to focus on the area where their expertise lies, reducing deaths by educating and training physicians to deal with the downstream consequences of upstream events, they must also focus increased attention on educating themselves and their trainees about the effect of racism, social disadvantage, and poor coordination of care on health, as well as their role in resolving these issues. Physicians must also reach out to their representatives in government to partner with them. Those leaders must recognize that when they hear about disparities in maternal mortality, focusing only on events in hospitals ignores the more dispositive issues that put Black women at risk in the first instance. KEY POINTS: · Structural racism contributes to maternal deaths.. · Coordination of postpartum care is critically important.. · U.S. health care system is complex and not patient friendly.., Competing Interests: None declared., (Thieme. All rights reserved.)

Importance: Reducing rates of unnecessary cesarean deliveries is both a national and a global health objective. However, there are limited national US data on trends in indications for low-risk cesarean delivery., Objective: To determine temporal trends in and indications for cesarean delivery among patients at low risk for the procedure over a 20-year period., Design, Setting, and Participants: This cross-sectional study analyzed 2000 to 2019 delivery hospitalizations using the National Inpatient Sample. Births at low risk for cesarean delivery were identified using a definition from the Society for Maternal-Fetal Medicine and additional criteria. Temporal trends in cesarean birth were analyzed using joinpoint regression to estimate the average annual percentage change (AAPC) with 95% CIs. Data analysis was performed from August 2022 to January 2023., Exposure: This analysis evaluated cesarean birth trends in a population at low risk for this procedure over a 20-year period., Main Outcomes and Measures: In addition to overall cesarean birth risk, cesarean deliveries for nonreassuring fetal status and labor arrest were individually analyzed., Results: Of an estimated 76.7 million delivery hospitalizations, 21.5 million were excluded according to the Society for Maternal-Fetal Medicine definition, and 14.7 million were excluded according to additional criteria. Of the estimated 40 517 867 deliveries included, 12.1% (4 885 716 deliveries) were by cesarean delivery. Cesarean deliveries among patients at low risk for the procedure increased from 9.7% to 13.9% between 2000 and 2009, plateaued, and then decreased from 13.0% to 11.1% between 2012 and 2019. The AAPC for cesarean delivery was 6.4% (95% CI, 5.2% to 7.6%) from 2000 to 2005, 1.2% from 2005 to 2009 (95% CI, -1.2% to 3.7%), and -2.2% from 2009 to 2019 (95% CI, -2.7% to -1.8%). Cesarean delivery for nonreassuring fetal status increased from 3.4% of all deliveries in 2000 to 5.1% in 2019 (AAPC, 2.1%; 95% CI, 1.7% to 2.5%). Cesarean delivery for labor arrest increased from 3.6% in 2000 to a peak of 4.8% in 2009 before decreasing to 2.7% in 2019. Cesarean deliveries for labor arrest increased during the first half of the study (2000-2009) for the active phase (from 1.5% to 2.1%), latent phase (from 1.1% to 1.5%), and second stage (from 0.9% to 1.3%) and then decreased from 2010 to 2019, from 2.1% to 1.7% for the active phase, from 1.5% to 1.2% for the latent phase, and from 1.2% to 0.9% for the second stage., Conclusions and Relevance: Cesarean deliveries among patients at low risk for cesarean birth appeared to decrease over the latter years of the study period, with cesarean deliveries for labor arrest becoming less common.

Objective: To create, implement, and evaluate the effectiveness of a cesarean delivery checklist on maternal and neonatal outcomes in a rural African hospital., Methods: Based on input from local authorities, WHO's Safe Surgical Checklist was modified for cesarean delivery and adapted for use in low-resource settings. Retrospective chart review between April and August 2013 in Kibogora Hospital, Nyamasheke, Rwanda, included the first 100 women undergoing cesarean after checklist implementation and the last 100 women undergoing cesarean before implementation. Checklist utilization was determined and degree of completeness assessed. Outcomes were compared between patients for whom the checklist was utilized and patients for whom the checklist was not utilized, in both pre and post-implementation groups., Results: Checklist utilization rate was 83.0% (83/100). Checklist utilization was associated with significant increases in documentation of estimated blood loss (91.6% [76/83] vs 0.9% [1/117], P<0.001) and antibiotic administration before incision (96.4% [80/83] vs 30.8% [36/117], P<0.001). It was also associated with decreased rates of hospitalization longer than the standard 4 days (19.3% [16/83] vs 70.1% [82/117], P<0.001)., Conclusion: Implementation of a cesarean delivery checklist via a culturally specific and resource-specific strategy resulted in high utilization rates and improved performance in key best practices by healthcare providers., (© 2020 International Federation of Gynecology and Obstetrics.)

Objective: To evaluate the perceptions of healthcare and traditional medicine providers regarding the type, indications, side effects, and prevalence of traditional medicine use amongst pregnant women in a rural Rwandan population., Methods: Six focus groups with physicians, nurses, and community health workers and four individual in-depth interviews with traditional medicine providers were held. Qualitative data was gathered using a structured questionnaire querying perceptions of the type, indications, side effects, and prevalence of use of traditional medicines in pregnancy., Results: The healthcare provider groups perceived a high prevalence of traditional botanical medicine use by pregnant women (50-80%). All three groups reported similar indications for use of the medicines and the socioeconomic status of the pregnant women who use them. The traditional medicine providers and the healthcare providers both perceived that the most commonly used medicine is a mixture of many plants, called Inkuri. The most serious side effect reported was abnormally bright green meconium with a poor neonatal respiratory drive. Thirty-five traditional medicines were identified that are used during pregnancy., Conclusion: Perceptions of high prevalence of use of traditional medicines during pregnancy with possible negative perinatal outcomes exist in areas of rural Rwanda.