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Background: Most countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries' (LMICs') midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration. Methods: Using the most recent available data from publicly available global databases for the period 2000–2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality. Results: In LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10–15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country. Conclusions: A complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes. [ABSTRACT FROM AUTHOR]

Background: Caesarean section (CS) rates are increasing globally, posing risks to women and babies. To reduce CS, educational interventions targeting pregnant women have been implemented globally, however, their effectiveness is varied. To optimise benefits of these interventions, it is important to understand which intervention components influence success. In this study, we aimed to identify essential intervention components that lead to successful implementation of interventions focusing on pregnant women to optimise CS use. Methods: We re-analysed existing systematic reviews that were used to develop and update WHO guidelines on non-clinical interventions to optimise CS. To identify if certain combinations of intervention components (e.g., how the intervention was delivered, and contextual characteristics) are associated with successful implementation, we conducted a Qualitative Comparative Analysis (QCA). We defined successful interventions as interventions that were able to reduce CS rates. We included 36 papers, comprising 17 CS intervention studies and an additional 19 sibling studies (e.g., secondary analyses, process evaluations) reporting on these interventions to identify intervention components. We conducted QCA in six stages: 1) Identifying conditions and calibrating the data; 2) Constructing truth tables, 3) Checking quality of truth tables; 4) Identifying parsimonious configurations through Boolean minimization; 5) Checking quality of the solution; 6) Interpretation of solutions. We used existing published qualitative evidence synthesis to develop potential theories driving intervention success. Results: We found successful interventions were those that leveraged social or peer support through group-based intervention delivery, provided communication materials to women, encouraged emotional support by partner or family participation, and gave women opportunities to interact with health providers. Unsuccessful interventions were characterised by the absence of at least two of these components. Conclusion: We identified four key essential intervention components which can lead to successful interventions targeting women to reduce CS. These four components are 1) group-based delivery, 2) provision of IEC materials, 3) partner or family member involvement, and 4) opportunity for women to interact with health providers. Maternal health services and hospitals aiming to better prepare women for vaginal birth and reduce CS can consider including the identified components to optimise health and well-being benefits for the woman and baby. [ABSTRACT FROM AUTHOR]

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). Plain language summary: The new WHO Labour Care Guide (LCG) is an innovative partograph that emphasises women-centred, evidence-based care during labour and childbirth. Together with clinicians working at four hospitals in India, we will develop and test a strategy to implement the LCG into routine care in labour wards of these hospitals. We will use a randomised trial design where this LCG strategy is introduced sequentially in each of the four hospitals, in a random order. We will collect data on all women giving birth and their newborns during this period and analyse whether the LCG strategy has any effects on the use of Caesarean section, women's and newborn's health outcomes, and women's experiences during labour and childbirth. While the trial is being conducted, we will also collect qualitative and quantitative data from doctors, nurses and midwives working in these hospitals, to understand their perspectives and experiences of using the LCG in their day-to-day work. In addition, we will collect economic data to understand how much the LCG strategy costs, and how much money it might save if it is effective. Through this study, our international collaboration will generate critical evidence and innovative tools to support implementation of the LCG in other countries. [ABSTRACT FROM AUTHOR]

Background: Rapid increases in caesarean section (CS) rates have been observed globally; however, CS rates exceeding 15% at a population-level have limited benefits for women and babies. Many interventions targeting healthcare providers have been developed to optimise use of CS, typically aiming to improve and monitor clinical decision-making. However, interventions are often complex, and effectiveness is varied. Understanding intervention and implementation features that likely lead to optimised CS use is important to optimise benefits. The aim of this study was to identify important components that lead to successful interventions to optimise CS, focusing on interventions targeting healthcare providers. Methods: We used Qualitative Comparative Analysis (QCA) to identify if certain combination of important intervention features (e.g. type of intervention, contextual characteristics, and how the intervention was delivered) are associated with a successful intervention as reflected in a reduction of CS. We included 21 intervention studies targeting healthcare providers to reduce CS, comprising of 34 papers reporting on these interventions. To develop potential theories driving intervention success, we used existing published qualitative evidence syntheses on healthcare providers' perspectives and experiences of interventions targeted at them to reduce CS. Results: We identified five important components that trigger successful interventions targeting healthcare providers: 1) training to improve providers' knowledge and skills, 2) active dissemination of CS indications, 3) actionable recommendations, 4) multidisciplinary collaboration, and 5) providers' willingness to change. Importantly, when one or more of these components are absent, dictated nature of intervention, where providers are enforced to adhere to the intervention, is needed to prompt successful interventions. Unsuccessful interventions were characterised by the absence of these components. Conclusion: We identified five important intervention components and combinations of intervention components which can lead to successful interventions targeting healthcare providers to optimise CS use. Health facility managers, researchers, and policy-makers aiming to improve providers' clinical decision making and reduce CS may consider including the identified components to optimise benefits. [ABSTRACT FROM AUTHOR]

Background: Recently, time-driven activity-based costing (TDABC) is put forward as an alternative, more accurate costing method to calculate the cost of a medical treatment because it allows the assignment of costs directly to patients. The objective of this paper is the application of a time-driven activity-based method in order to estimate the cost of childbirth at a maternal department. Moreover, this study shows how this costing method can be used to outline how childbirth costs vary according to considered patient and disease characteristics. Through the use of process mapping, TDABC allows to exactly identify which activities and corresponding resources are impacted by these characteristics, leading to a more detailed understanding of childbirth cost. Methods: A prospective cohort study design is performed in a maternity department. Process maps were developed for two types of childbirth, vaginal delivery (VD) and caesarean section (CS). Costs were obtained from the financial department and capacity cost rates were calculated accordingly. Results: Overall, the cost of childbirth equals €1894,12 and is mainly driven by personnel costs (89,0%). Monitoring after birth is the most expensive activity on the pathway, costing €1149,70. Significant cost variations between type of delivery were found, with VD costing €1808,66 compared to €2463,98 for a CS. Prolonged clinical visit (+ 33,3 min) and monitoring (+ 775,2 min) in CS were the main contributors to this cost difference. Within each delivery type, age, parity, number of gestation weeks and education attainment were found to drive cost variations. In particular, for VD an age > 25 years, nulliparous, gestation weeks > 40 weeks and higher education attainment were associated with higher costs. Similar results were found within CS for age, parity and number of gestation weeks. Conclusions: TDABC is a valuable approach to measure and understand the variability in costs of childbirth and its associated drivers over the full care cycle. Accordingly, these findings can inform health care providers, managers and regulators on process improvements and cost containment initiatives. [ABSTRACT FROM AUTHOR]

Background: Caesarean section (CS) is widely perceived as protective against obstetric brachial plexus injury (BPI), but few studies acknowledge the factors associated with such injury. The objectives of this study were therefore to aggregate cases of BPI after CS, and to illuminate risk factors for BPI. Methods: Pubmed Central, EMBASE and MEDLINE databases were searched using free text: ("brachial plexus injury" or "brachial plexus injuries" or "brachial plexus palsy" or "brachial plexus palsies" or "Erb's palsy" or "Erb's palsies" or "brachial plexus birth injury" or "brachial plexus birth palsy") and ("caesarean" or "cesarean" or "Zavanelli" or "cesarian" or "caesarian" or "shoulder dystocia"). Studies with clinical details of BPI after CS were included. Studies were assessed using the National Institutes for Healthy Study Quality Assessment Tool for Case Series, Cohort and Case-Control Studies. Main results: 39 studies were eligible. 299 infants sustained BPI after CS. 53% of cases with BPI after CS had risk factors for likely challenging handling/manipulation of the fetus prior to delivery, in the presence of considerable maternal or fetal concerns, and/or in the presence of poor access due to obesity or adhesions. Conclusions: In the presence of factors that would predispose to a challenging delivery, it is difficult to justify that BPI could occur due to in-utero, antepartum events alone. Surgeons should exercise care when operating on women with these risk factors. [ABSTRACT FROM AUTHOR]

Background: Respiratory functions may be impaired in cesarean section (C/S) delivery performed under spinal anesthesia (SA) and oxygen supplementation may be required. Therefore, we conducted a randomized controlled study aimed to evaluate the effects of different oxygen administrations in pregnant women on the lungs during C/S under SA using ultrasound and oxygen reserve index (ORI). Methods: We conducted a randomized, controlled, single-center study from May 1, 2021, to March 31, 2022. A total of 90 patients scheduled for C/S under SA were randomly divided into 3 groups. Following the SA, patients in group 0 were treated with room air, in Group 3 were administered 3 L/min O₂ with a nasal cannula (NC), in Group 6 were administered 6 L/min O₂ with a simple face mask. In addition to routine monitoring, ORI values were measured. Lung aeration was evaluated through the modified lung ultrasound score (LUS) before the procedure (T0), at minute 0 (T1), 20 (T2), and hour 6 (T3) after the procedure, and ∆LUS values were recorded. Results: After SA, the ORI values of Group 3 were higher than Group 0 at all times (p < 0.05), while the intraoperative 1st minute and the 10th, 25th and 40th minutes after delivery (p = 0.001, p = 0.027, p = 0.001, p = 0.019) was higher than Group 6. When the LUS values of each group were compared with the T0 values a decrease was observed in Group 3 and Group 6 (p < 0.001, p = 0.016). While ∆LUS values were always higher in Group 3 than in Group 0, they were higher only in T1 and T2 in Group 6. Conclusion: We determined that it would be appropriate to prefer 3 L/min supplemental oxygen therapy with NC in C/S to be performed under SA. [ABSTRACT FROM AUTHOR]

Background: We assessed the effect of different obstetric interventions and types of delivery on breastfeeding. Methods: A quantitative, cross-sectional study was carried out using an online questionnaire. Data collection was performed in 2021 in Hungary. We included biological mothers who had raised their at least 5-year-old child(ren) at home (N = 2,008). The questionnaire was completed anonymously and voluntarily. In addition to sociodemographic data (age, residence, marital status, education, occupation, income status, number of biological children, and anthropometric questions about the child and the mother), we asked about the interventions used during childbirth, and the different ways of infant feeding used. Statistical analysis was carried out using Microsoft Excel 365 and SPSS 25.0. Descriptive statistics, two-sample t tests, χ2 tests and ANOVA were used to analyse the relationship or differences between the variables (p < 0,05). Results: We found that in deliveries where synthetic oxytocin was used for both induction and acceleration, there was a higher incidence of emergency cesarean section. However, the occurrence of vaginal deliveries was significantly higher in cases where oxytocin administration was solely for the purpose of accelerating labour (p < 0.001).Mothers who received synthetic oxytocin also received analgesics (p < 0.001). Women giving birth naturally who used oxytocin had a lower success of breastfeeding their newborn in the delivery room (p < 0.001). Children of mothers who received obstetric analgesia had a higher rate of complementary formula feeding (p < 0.001). Newborns born naturally had a higher rate of breastfeeding in the delivery room (p < 0.001) and less formula feeding in the hospital (p < 0.001). Infants who were breastfed in the delivery room were breastfed for longer periods (p < 0.001). Exclusive breastfeeding up to six months was longer for infants born naturally (p = 0.005), but there was no difference in the length of breastfeeding (p = 0.081). Conclusions: Obstetric interventions may increase the need for further interventions and have a negative impact on early or successful breastfeeding. Trial registration: Not relevant. [ABSTRACT FROM AUTHOR]

Background: Georgia experienced an increase in maternal deaths (MD) during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, which warrants further investigation. This study aimed to assess associations between timing of SARS-CoV-2 infection during pregnancy and MD, post-delivery intensive care unit (ICU) admission, and caesarean section (CS) delivery. Methods: We performed a national birth registry-based cohort study of pregnant women who had completed 22 weeks of gestation and delivered between February 28, 2020, and August 31, 2022. The data were linked to coronavirus disease 2019 (COVID-19) testing, vital, and immunization registries. Pregnant women were classified into three groups: confirmed SARS-CoV-2 infection from conception through 31 days before delivery; confirmed infection within 30 days before or at delivery; and women negative for SARS-CoV-2 infection or without any test results (reference group). Multivariable logistic regression was used to calculate the adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results: Among 111,493 pregnant women, 16,751 had confirmed infection during pregnancy, and 7,332 were fully vaccinated against COVID-19 before delivery. Compared to the reference group, those with confirmed infection within 30 days before or at delivery experienced increased odds of MD (aOR: 43.11, 95% CI, 21.99–84.55), post-delivery ICU admission (aOR: 5.20, 95% CI, 4.05–6.67), and CS delivery (aOR: 1.11, 95% CI, 1.03–1.20). Conclusions: Pregnant women in Georgia with confirmed SARS-CoV-2 infection within 30 days before or at delivery experienced a considerably higher risk of MD and post-delivery ICU admission and a slightly higher risk for CS delivery. Additionally, the results highlighted that most pregnant women were not vaccinated against COVID-19. These findings should alert stakeholders that adherence to public health preventive measures needs to be improved. [ABSTRACT FROM AUTHOR]

Background: In the absence of medical necessity, opting for caesarean sections exposes mothers and neonates to increased risks of enduring long-term health problems and mortality. This ultimately results in greater economic burden when compared to the outcomes of spontaneous vaginal births. In Switzerland around 33% of all births are by caesarean section. However, the rate of caesarean sections without medical indication is still unknown. Therefore, we devise an identification strategy to differentiate caesarean sections without medical indication using routine data. In addition, we aim to categorize the influencing factors for women who undergo spontaneous vaginal births as opposed to those with caesarean sections without medical indication. Method: We use Swiss Federal Statistics data including 98.3% of all women giving birth from 2014 to 2018. To determine non-medically indicated caesarean sections in our dataset, we base our identification strategy on diagnosis-related groups, diagnosis codes, and procedure classifications. Subsequently, we compare characteristics of women who give birth by non-medically CS and external factors such as the density of practicing midwives to women with spontaneous vaginal birth. Logistic regression analysis measures the effect of factors, such as age, insurance class, income, or density of practicing midwives on non-medically indicated caesarean sections. Results: Around 8% of all Swiss caesarean sections have no medical indication. The regression analysis shows that higher age, supplemental insurance, higher income, and living in urban areas are associated with non-medically indicated caesarean sections, whereas a higher density of midwives decreases the likelihood of caesarean sections without medical indication. Conclusions: By identifying non-medically indicated caesarean sections using routine data, it becomes feasible to gain insights into the characteristics of impacted mothers as well as the external factors involved. Illustrating these results, our recommendation is to revise the incentive policies directed towards healthcare professionals. Among others, future research may investigate the potential of midwife-assisted pregnancy programs on strengthening spontaneous vaginal births in absence of medical complications. [ABSTRACT FROM AUTHOR]

Background: The prevalence of C-sections in India increased from 17.2% to 2006 to 21.5% in 2021. This study examines the variations in C-section prevalence and the factors correlating to these variations in Tamil Nadu (TN) and Chhattisgarh (CG). Methods: Delivery by C-section as the outcome variable and several demographic, socio-economic, and clinical variables were considered as explanatory variables to draw inferences from unit-level data from the National Family Health Survey (NFHS-4; 2015-16 and NFHS-5; 2019-21). Descriptive statistics, bivariate percentage distribution, Pearson's Chi-square test, and multivariate binary logistic regression models were employed. The Slope Index of Inequality (SII) and the Concentration Index (CIX) were used to analyse absolute and relative inequality in C-section rates across wealth quintiles in public- and private-sector institutions. Results: The prevalence of C-sections increased across India, TN and CG despite a decrease in pregnancy complications among the study participants. The odds of caesarean deliveries among overweight women were twice (OR = 2.11; 95% CI 1.95–2.29; NFHS-5) those for underweight women. Women aged 35–49 were also twice (OR = 2.10; 95% CI 1.92–2.29; NFHS-5) as likely as those aged 15–24 to have C-sections. In India, women delivering in private health facilities had nearly four times higher odds (OR = 3.90; 95% CI 3.74–4.06; NFHS-5) of having a C-section; in CG, the odds were nearly ten-fold (OR = 9.57; 95% CI:7.51,12.20; NFHS-5); and in TN, nearly three-fold (OR = 2.65; 95% CI-2.27-3.10; NFHS-5) compared to those delivering in public facilities. In public facilities, absolute inequality by wealth quintile in C-section prevalence across India and in CG increased in the five years until 2021, indicating that the rich increasingly delivered via C-sections. In private facilities, the gap in C-section prevalence between the poor (the bottom two quintiles) and the non-poor narrowed across India. In TN, the pattern was inverted in 2021, with an alarming 73% of the poor delivering via C-sections compared to 64% of those classified as non-poor. Conclusion: The type of health facility (public or private) had the most impact on whether delivery was by C-section. In India and CG, the rich are more likely to have C-sections, both in the private and in the public sector. In TN, a state with good health indicators overall, the poor are surprisingly more likely to have C-sections in the private sector. While the reasons for this inversion are not immediately evident, the implications are worrisome and pose public health policy challenges. [ABSTRACT FROM AUTHOR]

Background: Whether women should be able to decide on mode of birth in healthcare settings has been a topic of debate in the last few decades. In the context of a marked increase in global caesarean section rates, a central dilemma is whether pregnant women should be able to request this procedure without medical indication. Since 2015, Law 25,929 of Humanised Birth is in place in Argentina. This study aims at understanding the power relations between healthcare providers, pregnant women, and labour companions regarding decision-making on mode of birth in this new legal context. To do so, central concepts of power theory are used. Methods: This study uses a qualitative design. Twenty-six semi-structured interviews with healthcare providers were conducted in five maternity wards in different regions of Argentina. Participants were purposively selected using heterogeneity sampling and included obstetrician/gynaecologists (heads of department, specialists working in 24-h shifts, and residents) and midwives where available. Reflexive thematic analysis was used to inductively develop themes and categories. Results: Three themes were developed: (1) Healthcare providers reconceptualize decision-making processes of mode of birth to make women's voices matter; (2) Healthcare providers feel powerless against women's request to choose mode of birth; (3) Healthcare providers struggle to redirect women's decision regarding mode of birth. An overarching theme was built to explain the power relations between healthcare providers, women and labour companions: Healthcare providers' loss of beneficial power in decision-making on mode of birth. Conclusions: Our analysis highlights the complexity of the healthcare provider-woman interaction in a context in which women are, in practice, allowed to choose mode of birth. Even though healthcare providers claim to welcome women being an active part of the decision-making processes, they feel powerless when women make autonomous decisions regarding mode of birth. They perceive themselves to be losing beneficial power in the eyes of patients and consider fruitful communication on risks and benefits of each mode of birth to not always be possible. At the same time, providers perform an increasing number of CSs without medical indication when it is convenient for them, which suggests that paternalistic practices are still in place. Plain Language Summary: In the last few decades, there has been a debate on whether women should be able to choose if they haver a vaginal birth or a caesarean section. This debate has been framed by the fact that an increasing number of caesarean sections are being performed. Since 2015, Argentina has a Law of Humanised Birth. We conducted a study to understand the power relations between healthcare providers, pregnant women and labour companions in decision making on mode of birth in this new legal context. To do so, we used central concepts of power theory. We conducted 26 semi-structured interviews with healthcare providers in five maternity wards of Argentina. The interviewees were obstetrician/gynaecologists (heads of department, specialists working in 24-h shifts, and residents) and midwives where available. We used thematic analysis to build themes from the data. We discovered that healthcare providers perceive themselves to be losing beneficial power in decision-making on mode of birth. Even though they claim to want women to make autonomous decisions, they feel frustrated when this happens. They also perceive it to be more difficult to communicate with patients regarding the risks and benefits of vaginal birth and caesarean section. At the same time, providers carry out an increasing number of CSs without medical indication when it is convenient for them, which suggests that paternalistic practices are still in place. [ABSTRACT FROM AUTHOR]

Background: Caesarean section (CS) rates are rising. Shared decision making (SDM) is a component of patient-centered communication which requires adequate information and awareness. Women in Ghana have varying perceptions about the procedure. We sought to explore mothers' knowledge. perceptions and SDM-influencing factors about CSs. Methods: A transdisciplinary mixed-methods study was conducted at the maternity unit of Korle-Bu Teaching Hospital in Accra, Ghana from March to May, 2019. Data collection was done in four phases: in-depth interviews (n = 38), pretesting questionnaires (n = 15), three focus group discussions (n = 18) and 180 interviewer administered questionnaires about SDM preferences. Factors associated with SDM were analyzed using Pearson's Chi-square test and multiple logistic regression. Results: Mothers depicted a high level of knowledge regarding medical indications for their CS but had low level of awareness of SDM. The perception of a CS varied from dangerous, unnatural and taking away their strength to a life-saving procedure. The mothers had poor knowledge about pain relief in labour and at Caesarean section. Health care professionals attributed the willingness of mothers to be involved in SDM to their level of education. Husbands and religious leaders are key stakeholders in SDM. Insufficient consultation time was a challenge to SDM according to health care professionals and post-partum mothers. Women with parity ≥ 5 have a reduced desire to be more involved in shared decision making for Caesarean section. AOR = 0.09, CI (0.02–0.46). Conclusion: There is a high knowledge about the indications for CS but low level of awareness of and barriers to SDM. The fewer antenatal care visits mothers had, the more likely they were to desire more involvement in decision making. Aligned to respectful maternity care principles, greater involvement of pregnant women and their partners in decision making process could contribute to a positive pregnancy experience. Education, including religious leaders and decision- making tools could contribute to the process of SDM. [ABSTRACT FROM AUTHOR]

Background: Cardiotocography (CTG) is a screening test used to detect fetal hypoxia in labour. It has a high false positive rate resulting in many potentially unnecessary caesarean sections. Fetal blood sampling (FBS) is a second-line test of the acid-base status of the fetus. It is used to provide either reassurance that it is safe for labour to continue or objective evidence of compromise so that delivery can be expedited. Digital fetal scalp stimulation (dFSS) to elicit a fetal heart rate acceleration is an alternative less invasive second-line test of fetal wellbeing. This study aims to provide robust evidence on the role of these two second-line tests in assessing fetal wellbeing and potentially preventing operative delivery.Methods: A multi-centre parallel group randomised controlled trial (RCT) is planned in four maternity centres in Ireland. The study aims to recruit 2500 nulliparous women with a term (≥37+0 weeks) singleton pregnancy who require a second-line test of fetal wellbeing in labour due to an abnormal CTG. Women will be allocated randomly to dFSS or FBS on a 1:1 ratio. The primary outcome is caesarean section. With 1250 women in each arm, the study will have 90% power to detect a difference of 5-6%, at a two-sided alpha significance level of 5%, assuming a caesarean section rate of at least 20% in the dFSS group.Discussion: If the proposed study shows evidence that dFSS is a safe, reliable and effective alternative to FBS, this would have ground-breaking implications for labour management worldwide. It could potentially lead to a reduction in invasive procedures and emergency caesarean sections.Trial Registration: ClinicalTrials.gov NCT05306756. Registered on 31 March 2022. The trial commenced enrolment on 10 May 2022. Ethical committee approval has been granted by the Research Ethics Committee (REC) of each hospital: Dublin/CWIUH REC: 12.06.2019; Cork/UCC REC: 29.11.2019; Galway/NUIG REC: 06.09.2019; Limerick/UL REC: 30.09.2019. [ABSTRACT FROM AUTHOR]

Background: The use of intrapartum interventions is becoming increasingly common globally. Interventions during birth, including caesarean section (CS), epidural analgesia and synthetic oxytocin infusion, can be important in optimizing obstetric care, but have the potential to impact breastfeeding. This study aimed to identify whether women who have certain intrapartum interventions have greater odds of unfavourable breastfeeding outcomes, both the immediate post-partum period and in the months after birth. Methods: This was a population-based cohort study of singleton livebirths at ≥37 weeks' gestation between 2010 and 2018 in Victoria, Australia using routinely-collected state-wide data from the Victorian Perinatal Data Collection (VPDC) and the Child Development Information System (CDIS). The interventions included were pre-labour CS, in-labour CS, epidural analgesia, and synthetic oxytocin infusion (augmentation and/or induction of labour). Outcomes were formula supplementation in hospital, method of last feed before hospital discharge and breastfeeding status at 3-months and 6-months. Descriptive statistics and multivariable logistic regression models adjusting for potential confounders were employed. Results: In total, 599,191 women initiated breastfeeding. In-labour CS (aOR 1.96, 95%CI 1.93,1.99), pre-labour CS (aOR 1.75, 95%CI 1.72,1.77), epidural analgesia (aOR 1.45, 95%CI 1.43,1.47) and synthetic oxytocin infusion (aOR 1.24, 95%CI 1.22,1.26) increased the odds of formula supplementation in hospital. Long-term breastfeeding data was available for 105,599 infants. In-labour CS (aOR 0.79, 95%CI 0.76,0.83), pre-labour CS (aOR 0.73, 95%CI 0.71,0.76), epidural analgesia (aOR 0.77, 95%CI 0.75,0.80) and synthetic oxytocin infusion (aOR 0.89, 95%CI 0.86–0.92) decreased the odds of exclusive breastfeeding at 3-months post-partum, which was similar at 6-months. There was a dose-response effect between number of interventions received and odds of each unfavourable breastfeeding outcome. Conclusion: Common intrapartum interventions are associated with less favourable breastfeeding outcomes, both in hospital and in the months after birth. This confirms the importance of only undertaking interventions when necessary. When interventions are used intrapartum, an assessment and identification of women at increased risk of early discontinuation of breastfeeding has to be performed. Targeted breastfeeding support for women who have intrapartum interventions, when they wish to breastfeed, is important. [ABSTRACT FROM AUTHOR]

Background: The use of caesarean section has steadily increased, with Latin America being the region with the highest rates. Multiple factors account for that increase and the Robson classification is appropriate to compare determinants at the clinical level for caesarean section rates over time. The purpose of this study is to describe the evolution of caesarean section rates by Robson groups in Uruguay from 2008 to 2018 using a country level database.Methods: We included the records of all women giving birth in Uruguay (pregnancies ≥22 weeks and weights ≥500 g) with valid data in the mode of childbirth recorded in the Perinatal Information System database between 2008 and 2018. Caesarean section rates were calculated by Robson groups for each of the years included, disaggregated by care sector (public/private) and by geographical area (Capital City/Non-Capital), with time trends and their significance analyzed using linear regression models.Results: Of the total 485,263 births included in this research, the overall caesarean section rate was 43,1%. In 2018, among the groups at lower risk of caesarean section (1 to 4), the highest rates were seen in women in group 2B (98,8%), followed by those in group 4B (97,9%). A significant increase in the number of caesarean sections was seen in groups 2B (97,9 to 98,8%), 3 (8,36 to 11,1%) and 4 (A (22,7 to 26,9%) and B (95,4 to 97,9%) Significant growth was also observed in groups 5 (74,3 to 78,1%), 8 (90,6 to 95,5%), and 10 (39,1 to 46,7%). The private sector had higher rates of caesarean section for all groups throughout the period, except for women in group 9. The private sector in Montevideo presented the highest rates in the groups with the lowest risk of caesarean section (1, 2A, 3 and 4A), followed by the private sector outside of the capital.Conclusion: Uruguay is no exception to the increasing caesarean section trend, even in groups of women who have lower risk of requiring caesarean section. The implementation of interventions aimed at reducing caesarean section in the groups with lower obstetric risk in Uruguay is warranted. [ABSTRACT FROM AUTHOR]

Background: There is a tiered healthcare system in Australia to support maternal and child health, including, non-psychiatric day stay and residential parenting services (RPS) such as Tresillian and Karitane (in New South Wales [NSW]). RPS are unique to Australia, and currently there is limited information regarding the healthcare trajectory of women accessing RPS and if they are more likely to have admissions to other health facilities within the first-year post-birth. This study aimed to examine differences in hospital co-admissions for women and babies admitted to RPS in NSW in the year following birth compared to non-RPS admitted women.Methods: A linked population data study of all women giving birth in NSW 2000-2012. Statistical differences were calculated using chi-square and student t-tests.Results: Over the 12-year timeframe, 32,071 women and 33,035 babies were admitted to RPS, with 5191 of these women also having one or more hospital admissions (7607 admissions). The comparator group comprised of 99,242 women not admitted to RPS but having hospital admissions over the same timeframe (136,771 admissions). Statistically significant differences between cohorts were observed for the following parameters (p ≤ .001). Based upon calculated percentages, women who were admitted to RPS were more often older, Australian born, socially advantaged, private patients, and having their first baby. RPS admitted women also had more multiple births and labour and birth interventions (induction, instrumental birth, caesarean section, epidural, episiotomy). Their infants were also more often male and admitted to Special Care Nursery/Neonatal Intensive Care. Additionally, RPS admitted women had more admissions for mental health and behavioural disorders, which appeared to increase over time. There was no statistical difference between cohorts regarding the number of women admitted to a psychiatric facility; however, women attending RPS were more likely to have mood affective, or behavioural and personality disorder diagnoses.Conclusion: Women accessing RPS in the year post-birth were more socially advantaged, had higher birth intervention and more co-admissions and treatment for mental health disorders than those not accessing RPS. More research is needed into the impact of birth intervention and mental health issues on subsequent parenting difficulties. [ABSTRACT FROM AUTHOR]

Background: Rates of caesarean section (CS) delivery are increasing worldwide. CS delivery is often complicated by post-surgical infection, estimated to have ten times higher risk of infections than that of vaginal delivery. While widespread use of prophylactic antibiotics with CS has reduced post-CS infection, incidence may be reduced further by cleansing the vagina with betadine antiseptic wash prior to CS. However, reports are not consistent, and different antiseptics have been practised variably. Therefore, in order to ensure that the risks to the mother are as minimal as possible, it is important to determine whether vaginal irrigation with antiseptic wash reduces post-CS infection rate, and if so, which antiseptic is paramount.Methods: Women giving birth by elective or emergency CS will be assigned into either the intervention (1% povidone iodine (n = 125) or chlorhexidine (n = 125)) or the control (no-irrigation (n = 125)) group by using a block randomisation technique. Participants will receive vaginal cleansing with an intervention or no vaginal cleansing prior to CS. Follow-up will occur at day 14 and day 28 post-CS. A predeveloped questionnaire will be completed with patients' socio-demographic characteristics and required clinical and pregnancy-related information. All the fever, infection and readmission-related information will be completed from either the patient's or their record or at follow-up visits. Occurrence of post-CS infection, as measured by primary and secondary outcomes, will be compared between the groups.Discussion: The results of this study may provide important data to define the future uniform use of vaginal antiseptic wash immediately prior to CS and to determine the best antiseptic wash details in reducing post-operative infections or complications.Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000971932p . Registered on 28 September 2020. [ABSTRACT FROM AUTHOR]

Background: Previous research is inconclusive on the effects of mode of delivery on maternal health-related quality-of-life (HRQoL). We conducted a systematic review and meta-analysis to assess the current evidence for associations between mode of delivery and postpartum health-related quality-of-life.Methods: Electronic databases MEDLINE ALL (OVID), Web of Science, The Cochrane Library, CINAHL and EMBASE (OVID) were searched for English written articles investigating the relationship between mode of delivery and quality-of-life published form inception to 15th October 2020. Two reviewers independently screened titles and abstracts, assessed full texts, and extracted data. Meta-analysis was conducted where possible.Results: Twenty-one studies, including 19,879 women, met the inclusion criteria. A meta-analysis of 18 studies found HRQoL scores were significantly higher for women after vaginal delivery in comparison to caesarean (emergency and elective combined) (Effect Size (ES) 0.17, 95% CI 0.01-0.25, n = 7665) with highest scores after assisted vaginal delivery (ES 0.21, 95% CI 0.13-0.30, n = 2547). Physical functioning (ES 11.18, 95% CI = 2.29-20.06, n = 1746), physical role (ES 13.10, 95% CI = 1.16-25.05, n = 1471), vitality (ES 6.31, 95% CI = 1.14-10.29, n = 1746) and social functioning (ES 5.69, 95% CI = 1.26-10.11, n = 1746) were significantly higher after vaginal delivery compared to caesarean.Conclusions: Health-related quality-of-life scores were higher for women after vaginal delivery in comparison to caesarean section. Consequently, women should be encouraged to deliver vaginally where possible. The findings of this research should be available to the relevant population to help support informed choice. [ABSTRACT FROM AUTHOR]

Background: Caesarean section (CS) is an intervention to reduce maternal and perinatal mortality, for complicated pregnancy and labour. We analysed trends in the prevalence of birth by CS in Ghana from 1998 to 2014.Methods: Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the 1998-2014 Ghana Demographic and Health Surveys (GDHS) were analysed with respect of inequality in birth by CS. First, we disaggregated birth by CS by four equity stratifiers: wealth index, education, residence, and region. Second, we measured inequality through simple unweighted measures (Difference (D) and Ratio (R)) and complex weighted measures (Population Attributable Risk (PAR) and Population Attributable Fraction (PAF)). A 95% confidence interval was constructed for point estimates to measure statistical significance.Results: The proportion of women who underwent CS increased significantly between 1998 (4.0%) and 2014 (12.8%). Throughout the 16-year period, the proportion of women who gave birth by CS was positively skewed towards women in the highest wealth quintile (i.e poorest vs richest: 1.5% vs 13.0% in 1998 and 4.0% vs 27.9% in 2014), those with secondary education (no education vs secondary education: 1.8% vs 6.5% in 1998 and 5.7% vs 17.2% in 2014) and women in urban areas (rural vs urban 2.5% vs 8.5% in 1998 and 7.9% vs 18.8% in 2014). These disparities were evident in both complex weighted measures of inequality (PAF, PAR) and simple unweighted measures (D and R), although some uneven trends were observed. There were also regional disparities in birth by CS to the advantage of women in the Greater Accra Region over the years (PAR 7.72; 95% CI 5.86 to 9.58 in 1998 and PAR 10.07; 95% CI 8.87 to 11.27 in 2014).Conclusion: Ghana experienced disparities in the prevalence of births by CS, which increased over time between 1998 and 2014. Our findings indicate that more work needs to be done to ensure that all subpopulations that need medically necessary CS are given access to maternity care to reduce maternal and perinatal deaths. Nevertheless, given the potential complications with CS, we advocate that the intervention is only undertaken when medically indicated. [ABSTRACT FROM AUTHOR]

Background: Caesarean section (C-section) delivery is an important indicator of access to life-saving essential obstetric care. Yet, there is limited understanding of the costs of utilising C-section delivery care in sub-Saharan Africa. Thus, we estimated the direct and indirect patient cost of accessing C-section in Tanzania.Methods: Cross-sectional survey data of 2012 was used, which covered 3000 households from 11 districts in three regions. We interviewed women who had given births in the last 12 months before the survey to capture their experience of care. We used a regression model to estimate the effect of C-section on costs, while the degree of inequality on C-section coverage was assessed with a concentration index.Results: C-section increased the likelihood of paying for health care by 16% compared to normal delivery. The additional cost of C-section compared to normal delivery was 20 USD, but reduced to about 11 USD when restricted to public facilities. Women with C-section delivery spent an extra 2 days at the health facility compared to normal delivery, but this was reduced slightly to 1.9 days in public facilities. The distribution of C-section coverage was significantly in favour of wealthier than poorest women (CI = 0.2052, p < 0.01), and this pro-rich pattern was consistent in rural districts but with unclear pattern in urban districts.Conclusions: C-section is a life-saving intervention but is associated with significant economic burden especially among the poor families. More health resources are needed for provision of free maternal care, reduce inequality in access and improve birth outcomes in Tanzania. [ABSTRACT FROM AUTHOR]