Incidence and characteristics of pregnancy-related death across ten low- and middle-income geographical regions: secondary analysis of a cluster randomised controlled trial.

OBJECTIVE: The aim of this article is to describe the incidence and characteristics of pregnancy-related death in low- and middle-resource settings, in relation to the availability of key obstetric resources. DESIGN: This is a secondary analysis of a stepped-wedge cluster randomised controlled trial. SETTING: This trial was undertaken at ten sites across eight low- and middle-income countries in sub-Saharan Africa, India and Haiti. POPULATION: Institutional-level consent was obtained and all women presenting for maternity care were eligible for inclusion. METHODS: Pregnancy-related deaths were collected prospectively from routine data sources and active case searching. MAIN OUTCOME MEASURES: Pregnancy-related death, place, timing and age of maternal death, and neonatal outcomes in women with this outcome. RESULTS: Over 20 months, in 536 233 deliveries there were 998 maternal deaths (18.6/10 000, range 28/10 000-630/10 000). The leading causes of death were obstetric haemorrhage (36.0%, n = 359), hypertensive disorders of pregnancy (20.6%, n = 206), sepsis (14.1%, n = 141) and other (26.5%, n = 264). Approximately a quarter of deaths occurred prior to delivery (28.4%, n = 283), 35.7% (n = 356) occurred on the day of delivery and 35.9% (n = 359) occurred after delivery. Half of maternal deaths (50.6%; n = 505) occurred in women aged 20-29 years, 10.3% (n = 103) occurred in women aged under 20 years, 34.5% (n = 344) occurred in women aged 30-39 years and 4.6% (n = 46) occurred in women aged ≥40 years. There was no measured association between the availability of key obstetric resources and the rate of pregnancy-related death. CONCLUSIONS: The large variation in the rate of pregnancy-related death, irrespective of resource availability, emphasises that inequality and inequity in health care persists. TWEETABLE ABSTRACT: Inequality and inequity in pregnancy-related death persists globally, irrespective of resource availability.

A randomized clinical trial evaluating prophylactic single-dose vs prolonged course of antibiotics for caesarean section in a high HIV-prevalence setting.

The evidence that perioperative antibiotics for caesarean delivery are effective in reducing infective morbidity is unequivocal. In developing countries, especially those with high HIV-prevalence, clinicians have increasingly become anxious about the efficacy of perioperative antibiotics, hence the adoption of treatment regimens, as described in this study. We set out to investigate if these fears have a basis by conducting a randomised clinical trial. The setting was two tertiary units in a developing country with a significant HIV-prevalence. The outcome measures assessed were: pyrexia, wound infection, admission with puerperal sepsis, laparotomy for pelvic abscess and duration of hospital stay. There was no statistically significant difference between the two arms of the study with regard to the above outcomes. Our conclusion is that the two antibiotic regimens are equivalent in preventing infection, therefore there is no justification for subjecting patients to week-long antibiotics and the unnecessary increase in nurse workload.

Uptake of invasive testing following a positive triple test for Down's syndrome. Are midwives different counsellors compared with obstetricians?

A review of the uptake rate of diagnostic tests following a positive triple test was undertaken in the two maternity units of the Hull and East Yorkshire NHS Trust. In one unit, midwives were actively involved in counselling and in the other, counselling was performed by Consultant obstetricians. During the study period, there were 721 (7.1% positive rate) positive triple tests. Of these, 212 (29.4%) and 509 (70.6%) were counselled by midwives and Consultant obstetricians, respectively. There was no significant difference in uptake of amniocenteses or chorionic villous sampling with respect to the counsellor with an uptake of 60.4% in the midwife counselled group compared with 67.6% in the Consultant counselled group (p = NS). We believe the determinants of the uptake rate of a diagnostic test are patient centred if adequate counselling is provided. Midwives will continue to play a role in counselling and should be encouraged to do so to reduce the burden on obstetricians.

Maternal serum screening for Down syndrome: are women's perceptions changing?

OBJECTIVES: To document trends in serum screening for Down's syndrome. BACKGROUND: Trends in the uptake of serum screening for Down syndrome have not been documented in a UK population. DESIGN: A retrospective review of the rate of uptake in a unit that has offered serum screening for Down syndrome to all pregnant women. SETTING: A large north of England hospital that has offered universal Down syndrome screening using the 'triple test' since 1992. PATIENTS: A total of 47,998 women who booked for antenatal care. MAIN OUTCOME MEASURES: Uptake of serum screening for Down syndrome. METHODS: The results of the screening programme were contemporaneously recorded on a computer database, and the study team accessed the data. RESULTS: There was a significant reduction in the uptake of serum screening for Down syndrome from a maximum of 82.6% in 1993 to 41.4% in 2005. There was a significant but small trend upwards in the age of women accepting screening and also a significant trend in the increase in the screen-positive rates. CONCLUSIONS: The reduction in uptake of Down syndrome screening over the past 13 years must be taken into account when planning a screening programme. Other units should be encouraged to review their rate of uptake to determine if our data are representative of a wider trend.

Thromboprophylaxis for caesarean section--how can uptake and coverage be improved?

The objective of this study was to determine the proportion of patients requiring thromboprophylaxis and evaluate adherence to local protocols on thromboprophylaxis after caesarean section. This was a retrospective audit of 200 consecutive patients undergoing caesarean section between January and March 2002. The study was carried out at two obstetric units in Hull. We evaluated the proportion of patients requiring prophylaxis, appropriate and inappropriate treatment given and those omitted from receiving prophylaxis. Adherence to a risk assessment protocol was also assessed. The majority of women (84.5%) had at least one risk factor for thromboembolism. Use of a checklist did not increase the appropriate use of thromboprophylaxis and did not reduce inappropriate use. The checklist was used appropriately in only 54% of cases. Thromboprophylaxis has not been associated with problems if given after operation, thus the inappropriate administration is probably not a serious mistake. Universal prophylaxis with low molecular weight heparin would prevent at-risk women being missed and should be considered.