Risk factors for labour induction and augmentation: a multicentre prospective cohort study in India.

Background: Guidelines for labour induction/augmentation involve evaluating maternal and fetal complications, and allowing informed decisions from pregnant women. This study aimed to comprehensively explore clinical and non-clinical factors influencing labour induction and augmentation in an Indian population. Methods: A prospective cohort study included 9305 pregnant women from 13 hospitals across India. Self-reported maternal socio-demographic and lifestyle factors, and maternal medical and obstetric histories from medical records were obtained at recruitment (≥28 weeks of gestation), and women were followed up within 48 h after childbirth. Maternal and fetal clinical information were classified based on guidelines into four groups of clinical factors: (i) ≥2 indications, (ii) one indication, (iii) no indication and (iv) contraindication. Associations of clinical and non-clinical factors (socio-demographic, healthcare utilisation and lifestyle related) with labour induction and augmentation were investigated using multivariable logistic regression analyses. Findings: Over two-fifths (n = 3936, 42.3%, 95% confidence interval [CI] 41.3-43.3%) of the study population experienced labour induction and more than a quarter (n = 2537, 27.3%, 95% CI 26.4-28.2%) experienced augmentation. Compared with women with ≥2 indications, those with one (adjusted odds ratio [aOR] 0.50, 95% CI 0.42-0.58) or no indication (aOR 0.24, 95% CI 0.20-0.28) or with contraindications (aOR 0.12, 95% CI 0.07-0.20) were less likely to be induced, adjusting for non-clinical characteristics. These associations were similar for labour augmentation. Notably, 34% of women who were induced or augmented did not have any clinical indication. Several maternal demographic (age at labour, parity and body mass index in early pregnancy), healthcare utilization (number of antenatal check-ups, duration of iron-folic acid supplementation and individuals managing childbirth) and socio-economic factors (religion, living below poverty line, maternal education and partner's occupation) were independently associated with labour induction and augmentation. Interpretation: Although decisions about induction and augmentation of labour in our study population in India were largely guided by clinical recommendations, we cannot ignore that more than a third of the women did not have an indication. Decisions could also be influenced by non-clinical factors which need further research. Funding: The MaatHRI platform is funded by a Medical Research Council Career Development Award (Grant Ref: MR/P022030/1) and a Transition Support Award (Grant Ref: MR/W029294/1).

Maternal and fetal factors associated with stillbirth in singleton pregnancies in 13 hospitals across six states in India: A prospective cohort study.

OBJECTIVE: This study aimed to investigate the incidence of and risk factors for stillbirth in an Indian population. METHODS: We conducted a secondary data analysis of a hospital-based cohort from the Maternal and Perinatal Health Research collaboration, India (MaatHRI), including pregnant women who gave birth between October 2018-September 2023. Data from 9823 singleton pregnancies recruited from 13 hospitals across six Indian states were included. Univariable and multivariable Poisson regression analysis were performed to examine the relationship between stillbirth and potential risk factors. Model prediction was assessed using the area under the receiver-operating characteristic (AUROC) curve. RESULTS: There were 216 stillbirths (48 antepartum and 168 intrapartum) in the study population, representing an overall stillbirth rate of 22.0 per 1000 total births (95% confidence interval [CI]: 19.2-25.1). Modifiable risk factors for stillbirth were: receiving less than four antenatal check-ups (adjusted relative risk [aRR]: 1.75, 95% CI: 1.25-2.47), not taking any iron and folic acid supplementation during pregnancy (aRR: 7.23, 95% CI: 2.12-45.33) and having severe anemia in the third trimester (aRR: 3.37, 95% CI: 1.97-6.11). Having pregnancy/fetal complications such as hypertensive disorders of pregnancy (aRR: 1.59, 95% CI: 1.03-2.36), preterm birth (aRR: 4.41, 95% CI: 3.21-6.08) and birth weight below the 10th percentile for gestational age (aRR: 1.35, 95% CI: 1.02-1.79) were also associated with an increased risk of stillbirth. Identified risk factors explained 78.2% (95% CI: 75.0%-81.4%) of the risk of stillbirth in the population. CONCLUSION: Addressing potentially modifiable antenatal factors could reduce the risk of stillbirths in India.

Social responsiveness: The key ingredient to achieve social accountability in education and health care.

While social accountability (SA) is regarded as an obligation or mandate for medical school administration, it runs the danger of becoming a bureaucratic checkbox. Compassion which leads to social responsiveness (SR), in contrast, is often recognized as an individual characteristic, detached from the public domain. The two, however, complement each other in practice. Institutions must be truly socially accountable, which is possible if there is spontaneous SR to the needs, and is fueled by compassion. Compassion in this article is defined as a "feeling for other people's sufferings, and the desire to act to relieve the suffering." Compassion has a long history, whereas SA is more recently described concept that follows the historical development of social justice. SR is the moral or ethical duty of an individual to behave in a way that benefits society. Not everyone feels the need to do something for others. Even if the need is felt, there may be a lack of will to act for the needs or to act effectively to fulfill the needs of society. The reasons are many, some visible and others not. SR provides the basis for being compassionate; hence, medical schools need to include SR as a criterion in their admissions process for student recruitment and inculcate compassion in health professions education and health care. By fostering SR and engaging compassion and self-compassion to achieve SA, we can humanize medical education systems and health care.

The complex relationship between iron status and anemia in pregnant and postpartum women in India: Analysis of two Indian study cohorts of uncomplicated pregnancies.

Low hemoglobin is widely used as an indicator of iron deficiency anemia in India and other low-and-middle income counties, but anemia need not accurately reflect iron deficiency. We examined the relationship between hemoglobin and biomarkers of iron status in antenatal and postnatal period. Secondary analysis of uncomplicated singleton pregnancies in two Indian study cohorts: 1132 antenatal women in third trimester and 837 postnatal women 12-72 h after childbirth. Associations of hemoglobin with ferritin in both data sets, and with sTfR, TSAT, and hepcidin in the postnatal cohort were examined using multivariable linear regression. Multinomial logistic regression was used to examine the association between severity of anemia and iron status. Regression models were adjusted for potential confounders. Over 55% of the women were anemic; 34% of antenatal and 40% of postnatal women had low ferritin, but 4% antenatal and 6% postnatal women had high ferritin. No evidence of association between hemoglobin and ferritin was observed (antenatal: adjusted coefficient [aCoef] -0.0004, 95% confidence interval [CI] -0.001, 0.001; postnatal: aCoef -0.0001, 95% CI -0.001, 0.001). We found a significant linear association of hemoglobin with sTfR (aCoef -0.04, 95% CI -0.07, -0.01), TSAT (aCoef -0.005, 95% CI -0.008, -0.002), and hepcidin (aCoef 0.02, 95% CI 0.02, 0.03) in postnatal women. Likelihood of low ferritin was more common in anemic than non-anemic women, but high ferritin was also more common in women with severe anemia in both cohorts. Causes of anemia in pregnant and postpartum women in India are multifactorial; low hemoglobin alone is not be a useful marker of iron deficiency.

Relationship between anaemia, coagulation parameters during pregnancy and postpartum haemorrhage at childbirth: a prospective cohort study.

OBJECTIVES: To investigate the association between coagulation parameters and severity of anaemia (moderate anaemia: haemoglobin (Hb) 7-9.9 g/dL and severe anaemia: Hb <7 g/dL) during pregnancy and relate these to postpartum haemorrhage (PPH) at childbirth. DESIGN: A prospective cohort study of pregnant women recruited in the third trimester and followed-up after childbirth. SETTING: Ten hospitals across four states in India. PARTICIPANTS: 1342 pregnant women. INTERVENTION: Not applicable. METHODS: Hb and coagulation parameters: fibrinogen, D-dimer, D-dimer/fibrinogen ratio, platelets and international normalised ratio (INR) were measured at baseline. Participants were followed-up to measure blood loss within 2 hours after childbirth and PPH was defined based on blood loss and clinical assessment. Associations between coagulation parameters, Hb, anaemia and PPH were examined using multivariable logistic regression models. OUTCOMES MEASURES: Adjusted OR with 95% CI. RESULTS: In women with severe anaemia during the third trimester, the D-dimer was 27% higher, mean fibrinogen 117 mg/dL lower, D-dimer/fibrinogen ratio 69% higher and INR 12% higher compared with women with no/mild anaemia. Mean platelets in severe anaemia was 37.8×109/L lower compared with women with moderate anaemia. Similar relationships with smaller effect sizes were identified for women with moderate anaemia compared with women with no/mild anaemia. Low Hb and high INR at third trimester of pregnancy independently increased the odds of PPH at childbirth, but the other coagulation parameters were not found to be significantly associated with PPH. CONCLUSION: Altered blood coagulation profile in pregnant women with severe anaemia could be a risk factor for PPH and requires further evaluation.

Medical Students' and Trainees' Country-By-Gender Profiles: Hofstede's Cultural Dimensions Across Sixteen Diverse Countries.

PURPOSE: The global mobility of medical student and trainee populations has drawn researchers' attention to consider internationalization in medical education. Recently, researchers have focused on cultural diversity, predominately drawing on Hofstede's cross-cultural analysis of cultural dimensions from general population data to explain their findings. However, to date no research has been specifically undertaken to examine cultural dimensions within a medical student or trainee population. This is problematic as within-country differences between gender and professional groups have been identified within these dimensions. We address this gap by drawing on the theoretical concept of national context effects: specifically Hofstede's six-dimensional perspective. In doing so we examine medical students' and trainees' country profiles across dimensions, country-by-gender clustering, and differences between our data and Hofstede's general population data. METHODS: We undertook a cross-cultural online questionnaire study (eight languages) containing Hofstede's 2013 Values Survey. Our questionnaire was live between 1st March to 19th Aug 2018, and December 2018 to mitigate country holiday periods. We recruited undergraduate medical students and trainees with at least 6-months' clinical training using school-specific methods including emails, announcements, and snowballing. RESULTS: We received 2,529 responses. Sixteen countries were retained for analyses (n = 2,307, 91%): Australia, Chile, China, Hong Kong, India, Indonesia, Ireland, Israel, Japan, Malaysia, New Zealand, Pakistan, South Africa, South Korea, Sri-Lanka, Taiwan. Power distance and masculinity are homogenous across countries. Uncertainty avoidance shows the greatest diversity. We identified four country clusters. Masculinity and uncertainty are uncorrelated with Hofstede's general population data. CONCLUSIONS: Our medical student and trainee data provides medical education researchers with more appropriate cultural dimension profiles than those from general population data. Country cluster profiles stimulate useful hypotheses for further research, especially as patterning between clusters cuts across traditional Eastern-Western divides with national culture being stronger than gendered influences. The Uncertainty dimension with its complex pattern across clusters is a particularly fruitful avenue for further investigation.

Maternal and perinatal Health Research Collaboration, India (MaatHRI): methodology for establishing a hospital-based research platform in a low and middle income country setting.

Background: Maternal and perinatal Health Research collaboration, India (MaatHRI) is a research platform that aims to improve evidence-based pregnancy care and outcomes for mothers and babies in India, a country with the second highest burden of maternal and perinatal deaths. The objective of this paper is to describe the methods used to establish and standardise the platform and the results of the process. Methods: MaatHRI is a hospital-based collaborative research platform. It is adapted from the UK Obstetric Surveillance System (UKOSS) and built on a pilot model (IndOSS-Assam), which has been extensively standardised using the following methods: (i) establishing a network of hospitals; (ii) setting up a secure system for data collection, storage and transfer; (iii) developing a standardised laboratory infrastructure; and (iv) developing and implementing regulatory systems. Results: MaatHRI was established in September 2018. Fourteen hospitals participate across four states in India - Assam, Meghalaya, Uttar Pradesh and Maharashtra. The research team includes 20 nurses, a project manager, 16 obstetricians, two pathologists, a public health specialist, a general physician and a paediatrician. MaatHRI has advanced standardisation of data and laboratory parameters, real-time monitoring of data and participant safety, and secure transfer of data. Four observational epidemiological studies are presently being undertaken through the platform. MaatHRI has enabled bi-directional capacity building. It is overseen by a steering committee and a data safety and monitoring board, a process that is not normally used, but was found to be highly effective in ensuring data safety and equitable partnerships in the context of low and middle income countries (LMICs). Conclusion: MaatHRI is the first prototype of UKOSS and other similar platforms in a LMIC setting. The model is built on existing methods but applies new standardisation processes to develop a collaborative research platform that can be replicated in other LMICs.

Trends in hysterectomy for genital prolapse: rural experience.

The present study was conducted to investigate the trends of vaginal hysterectomy for genital prolapse in last 20 years by analyzing case records of affected women. During the analysis period, 4831 women underwent hysterectomy; records of 4223 (87.5%) were available. Of these, 911 (21.6%), 2.7% of 34,080 gynecological admissions, had vaginal hysterectomy for genital prolapse (study subjects). Eighty percent women who had vaginal hysterectomy for genital prolapse were over 40 years of age; however, most of these women had had the disorder for years before they presented. Only 4 (0.4%) women had not given birth, 874 (96%) women had had two or more births, and 383 (42%) had had 5 or more births. Having given birth was the major factor responsible for genital prolapse. In all, 94.2% of women presented with something coming out of the vagina." Some women presented with abnormal vaginal bleeding or pain in abdomen as the chief complaint although they had had uterovaginal prolapse for years. There was no mortality and morbidity decreased over the years. There has been no change in the rate of vaginal hysterectomy for genital prolapse over the years. Surgical morbidity decreased trend, possibly because of the preoperative, intraoperative, and postoperative precautions taken, especially preoperative treatment of urinary and genital tract infection. Attempts need to be made to have safe births and a healthy life style so as to prevent genital prolapse and in case it occurs, therapy to prevent progression so that major interventions like hysterectomy are averted. Meticulous preoperative evaluation and planned therapy help in reducing surgical morbidity, if surgery becomes essential.

Fertility preservation in gynecological cancers.

For cancers of reproductive system in women, fertility preservation is complex. Fertility is also affected by therapies, however prevention is possible. Radiotherapy affects gonads, uterus, and subsequent pregnancy outcomes in all ages. However, degree and damage depend on dose, irradiation field, and age at the time of exposure. Ovarian transposition is considered if ovarian involvement is unlikely. Gonadotoxic effects of chemotherapy are related to agent's type, cumulative doses, age, and ovarian reserve. Some agents are highly toxic. Rendering follicular development quiescent by suppression of gonadotropins does reduce the ovarian damage. Simple or radical trachelectomy can be used in early cervical cancer. Fertility saving surgery is possible only in early stage low grade epithelial cancers of the ovary, however, in germ cell tumors even in advanced stages it may be possible to preserve fertility. There are no standard recommendations for endometrial cancer. Embryo, oocyte, and ovarian tissue cryopreservation are possible. The human embryo is very resistant to damage. In view of these possibilities, it is advocated that attention to long term health and quality of life in gonadotoxic therapy must be incorporated into plans as early as possible.