Assessing the Gap Between Women's Expectations and Perceptions of the Quality of Intrapartum Care in Jordan: A Two-Stage Study Using the SERVQUAL Model.

INTRODUCTION: Although Jordan has made significant progress toward expanding the utilization of facility-based intrapartum care, prior research highlights that poor service quality is still persistent. This study aimed to identify quality gaps between women's expectations and perceptions of the actual intrapartum care received, while exploring the contributing factors. METHODS: Utilizing a pre-post design, quality gaps in intrapartum care were assessed among 959 women pre- and postchildbirth at a prominent tertiary hospital in northern Jordan. Data were gathered using the SERVQUAL scale, measuring service quality across reliability, responsiveness, tangibles, assurance, and empathy dimensions. RESULTS: The overall mean gap score between women's expectations and perceptions of the quality of intrapartum care was -0.60 (±0.56). The lowest and highest mean gap scores were found to be related to tangibles and assurance dimensions, -0.24 (±0.39) and -0.88 (±0.35), respectively. Significant negative quality gaps were identified in the dimensions of assurance, empathy, and responsiveness, as well as overall service quality (p < 0.001). The MLR analyses highlighted education (ß = 0.61), mode of birth (ß = -0.60), admission timing (ß = -0.41), continuity of midwifery care (ß = -0.43), physician's gender (ß = -0.62), active labour duration (ß = 0.37), and pain management (ß = -0.33) to be the key determinants of the overall quality gap in intrapartum care. CONCLUSION: Our findings underscore the importance of fostering a labour environment that prioritizes enhancing caregivers' empathetic, reassuring, and responsive skills to minimize service quality gaps and enhance the overall childbirth experience for women in Jordan. PATIENT OR PUBLIC CONTRIBUTION: This paper is a collaborative effort involving women with lived experiences of childbirth, midwives, and obstetrics and gynaecologist physicians. The original idea, conceptualization, data generation, and coproduction, including manuscript editing, were shaped by the valuable contributions of stakeholders with unique perspectives on intrapartum care in Jordan.

Challenges to the implementation of a multi-level intervention to reduce mistreatment of women during childbirth in Iran: a qualitative study using the Consolidated Framework for Implementation Research.

BACKGROUND: Mistreatment during childbirth is a growing concern worldwide, especially in developing countries, such as Iran. In response, we launched a comprehensive implementation research (IR) project to reduce mistreatment during childbirth and enhance positive birth experiences in birth facilities. This study identified the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth using the Consolidated Framework for Implementation Research (CFIR). METHODS: An exploratory qualitative study, involving 30 in-depth interviews, was conducted between July 2022 and February 2023. Participants included a purposive sample of key stakeholders at different levels of the health system (macro: Ministry of Health and Medical Education; meso: universities of medical sciences and health services; and micro: hospitals) with sufficient knowledge, direct experience, and/or collaboration in the implementation of the studied interventions. Interviews were transcribed verbatim and coded using directed qualitative content analysis (CFIR constructs) in MAXQDA 18. RESULTS: The identified challenges were: (1) individual level (childbirth preparation classes: e.g., adaptability, design quality and packaging, cosmopolitanism; presence of birth companions: e.g., patient needs and resources, structural characteristics, culture); (2) healthcare provider level (integrating respectful maternity care into in-service training: e.g., relative priority, access to knowledge and information, reflecting and evaluating); (3) hospital level (evaluating the performance of maternity healthcare providers: e.g., executing, external policies and incentives); and (4) national health system level (implementation of pain relief during childbirth guidelines: e.g., networks and communications, patient needs and resources, executing, reflecting and evaluating). CONCLUSIONS: This study provides a clear understanding of the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth and highlights potential implications for policy makers and practitioners of maternal health programs. We encourage them to take the lessons learned from this study and revise their current programs and policies regarding the quality of maternity care by focusing on the identified challenges.

Evidence suggests that mistreatment during childbirth is a growing concern worldwide, especially in developing countries, such as Iran. In this qualitative study, through 30 in-depth interviews with key stakeholders at different levels of the health system (macro: Ministry of Health and Medical Education; meso: universities of medical sciences and health services; and micro: hospitals), we identified the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth using the Consolidated Framework for Implementation Research (CFIR). The data were analyzed using directed content analysis and a deductive approach in MAXQDA 18 software. The identified challenges were: (1) individual level (childbirth preparation classes: e.g., adaptability; presence of birth companions: e.g., patient needs and resources); (2) healthcare provider level (integrating respectful maternity care into in-service training: e.g., relative priority); (3) hospital level (evaluating the performance of maternity healthcare providers: e.g., executing, external policies and incentives); and (4) national health system level (implementation of pain relief childbirth guidelines: e.g., networks and communications). This study provides a clear understanding of the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth; and highlights potential implications for policy makers and practitioners of maternal health programs.

Implementation of the WHO Safe Childbirth Checklist: a scoping review protocol.

INTRODUCTION: The WHO Safe Childbirth Checklist (WHO SCC) was developed to accelerate adoption of essential practices that prevent maternal and neonatal morbidity and mortality during childbirth. This study aims to summarise the current landscape of organisations and facilities that have implemented the WHO SCC and compare the published strategies used to implement the WHO SCC implementation in both successful and unsuccessful efforts. METHODS AND ANALYSIS: This scoping review protocol follows the guidelines of the Joanna Briggs Institute. Data will be collected and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews report. The search strategy will include publications from the databases Scopus, PubMed, Embase, CINAHL and Web of Science, in addition to a search in grey literature in The National Library of Australia's Trobe, DART-Europe E-Theses Portal, Electronic Theses Online Service, Theses Canada, Google Scholar and Theses and dissertations from Latin America. Data extraction will include data on general information, study characteristics, organisations involved, sociodemographic context, implementation strategies, indicators of implementation process, frameworks used to design or evaluate the strategy, implementation outcomes and final considerations. Critical analysis of implementation strategies and outcomes will be performed with researchers with experience implementing the WHO SCC. ETHICS AND DISSEMINATION: The study does not require an ethical review due to its design as a scoping review of the literature. The results will be submitted for publication to a scientific journal and all relevant data from this study will be made available in Dataverse. TRIAL REGISTRATION NUMBER: https://doi.org/10.17605/OSF.IO/RWY27.

Audit as a tool for improving obstetric care in low- and middle-income countries.

Maternal and/or perinatal death review or audits aim to improve the quality of health services and reduce deaths due to causes identified. A death review audit cycle identifies causes of deaths and possible modifiable factors, these can point to potential breaks in the continuity of health care and other health systems faults and challenges. It is an important function of audit cycles to develop, implement, monitor, and review action plans to improve the service. The WHO has produced two handbooks (Making Every Baby Count and Monitoring Emergency Obstetric Care) to guide maternal and perinatal death reviews. Health worker related factors accounts for two thirds of aspects that, if done differently may have prevented the adverse outcome. This emphasises the need for skilled health care workers at every delivery and for deliveries to take place in health facilities.

Quality improvement efforts directed at optimal umbilical cord management in delivery room.

Delayed or deferred cord clamping (DCC) and umbilical cord milking (UCM) benefit all infants by optimizing fetal-neonatal transition and placental transfusion. Even though DCC is recommended by almost all maternal and neonatal organizations, it has not been universally implemented. There is considerable variation in umbilical cord management practices across institutions. In this article, we provide examples of successful quality improvement (QI) initiatives to implement optimal cord management in the delivery room. We discuss a number of key elements that should be considering among those undertaking QI efforts to implement DCC and UCM including, multidisciplinary team collaboration, development of theory for change, mapping of the current and ideal process and workflow for cord management, and creation of a unit-specific evidence-based protocol for cord management. We also examine important strategies for implementation and provide suggestions for developing a system for measurement and benchmarking.

Organization and quality of care in childbirth in private for-profit maternity units in France: Risks of the deprofessionalization of midwives.

OBJECTIVE: In France, in 2007-2009, the risk of peripartum maternal mortality, especially the one due to hemorrhage, was higher in the private for-profit maternity units than in university maternity units. Our research, a component of the MATORG project, aimed to characterize the organization of care around childbirth in these private clinics to analyze how it might influence the quality and safety of care. MATERIAL AND METHODS: We conducted a qualitative survey in 2018 in the maternity units of two private for-profit clinics in the Paris region, interviewing 33 staff members (midwives, obstetricians, anesthesiologists, childcare assistants and managers) and observing in the delivery room for 20 days. The perspective of the sociology of organizations guided our data analysis. FINDINGS/RESULTS: Our study distinguished three principal risk factors for the safety of care in maternity clinics. The division of labor among healthcare professionals threatens the maintenance of midwives' competencies and makes it difficult for these clinics to keep midwives on staff. The mode of remuneration of both midwives and obstetricians incentivizes overwork by both, inducing fatigue and decreasing vigilance. Finally the clinical decision-making of some obstetricians is not collegial and creates conflicts with midwives, who criticize the technicization of childbirth. Some demotivated midwives no longer consider themselves responsible for patients' safety. CONCLUSIONS: The organization of work in private maternity units can put the safety of care around childbirth at risk. The division of labor, staff scheduling/planning, and a lack of collegiality in decision-making increase the risk of deprofessionalizing midwives.

Guideline nº 431: postpartum hemorrhage and hemorrhagic shock

This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock. Benefits, harms, and costs Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays. Medical literature, PubMed, ClinicalTrials.gov, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists.

Inclusive, supportive and dignified maternity care (SDMC)-Development and feasibility assessment of an intervention package for public health systems: A study protocol.

INTRODUCTION: Mistreatment, discrimination, and poor psycho-social support during childbirth at health facilities are common in lower- and middle-income countries. Despite a policy directive from the World Health Organisation (WHO), no operational model exists that effectively demonstrates incorporation of these guidelines in routine facility-based maternity services. This early-phase implementation research aims to develop, implement, and test the feasibility of a service-delivery strategy to promote the culture of supportive and dignified maternity care (SDMC) at public health facilities. METHODS: Guided by human-centred design approach, the implementation of this study will be divided into two phases: development of intervention, and implementing and testing feasibility. The service-delivery intervention will be co-created along with relevant stakeholders and informed by contextual evidence that is generated through formative research. It will include capacity-building of maternity teams, and the improvement of governance and accountability mechanisms within public health facilities. The technical content will be primarily based on WHO's intrapartum care guidelines and mental health Gap Action Programme (mhGAP) materials. A mixed-method, pre-post design will be used for feasibility assessment. The intervention will be implemented at six secondary-level healthcare facilities in two districts of southern Sindh, Pakistan. Data from multiple sources will be collected before, during and after the implementation of the intervention. We will assess the coverage of the intervention, challenges faced, and changes in maternity teams' understanding and attitude towards SDMC. Additionally, women's maternity experiences and psycho-social well-being-will inform the success of the intervention. EXPECTED OUTCOMES: Evidence from this implementation research will enhance understanding of health systems challenges and opportunities around SDMC. A key output from this research will be the SDMC service-delivery package, comprising a comprehensive training package (on inclusive, supportive and dignified maternity care) and a field tested strategy to ensure implementation of recommended practices in routine, facility-based maternity care. Adaptation, Implementation and evaluation of SDMC package in diverse setting will be way forward. The study has been registered with clinicaltrials.gov (Registration number: NCT05146518).

"Even though they insult us, the delivery they give us is the greatest thing": a qualitative study contextualizing women's experiences with facility-based maternal health care in Ethiopia.

BACKGROUND: Globally, amidst increased utilization of facility-based maternal care services, there is continued need to better understand women's experience of care in places of birth. Quantitative surveys may not sufficiently characterize satisfaction with maternal healthcare (MHC) in local context, limiting their interpretation and applicability. The purpose of this study is to untangle how contextual and cultural expectations shape women's care experience and what women mean by satisfaction in two Ethiopian regions. METHODS: Health center and hospital childbirth care registries were used to identify and interview 41 women who had delivered a live newborn within a six-month period. We used a semi-structured interview guide informed by the Donabedian framework to elicit women's experiences with MHC and delivery, any prior delivery experiences, and recommendations to improve MHC. We used an inductive analytical approach to compare and contrast MHC processes, experiences, and satisfaction. RESULTS: Maternal and newborn survival and safety were central to women's descriptions of their MHC experiences. Women nearly exclusively described healthy and safe deliveries with healthy outcomes as 'satisfactory'. The texture behind this 'satisfaction', however, was shaped by what mothers bring to their delivery experiences, creating expectations from events including past births, experiences with antenatal care, and social and community influences. Secondary to the absence of adverse outcomes, health provider's interpersonal behaviors (e.g., supportive communication and behavioral demonstrations of commitment to their births) and the facility's amenities (e.g., bathing, cleaning, water, coffee, etc) enhanced women's experiences. Finally, at the social and community levels, we found that family support and material resources may significantly buffer against negative experiences and facilitate women's overall satisfaction, even in the context of poor-quality facilities and limited resources. CONCLUSION: Our findings highlight the importance of understanding contextual factors including past experiences, expectations, and social support that influence perceived quality of MHC and the agency a woman has to negotiate her care experience. Our finding that newborn and maternal survival primarily drove women's satisfaction suggests that quantitative assessments conducted shortly following delivery may be overly influenced by these outcomes and not fully capture the complexity of women's care experience.

Do high-deductible health plans affect price paid for childbirth?

OBJECTIVE: To test whether out-of-pocket costs and negotiated hospital prices for childbirth change after enrollment in high-deductible health plans (HDHPs) and whether price effects differ in markets with more hospitals. DATA SOURCES: Administrative medical claims data from 2010 to 2014 from three large commercial insurers with plans in all U.S. states provided by the Health Care Cost Institute (HCCI). STUDY DESIGN: I identify employer groups that switched from non-HDHPs in 1 year to HDHPs in a subsequent year. I estimate enrollees' change in out-of-pocket costs and negotiated hospital prices for childbirth after HDHP switch, relative to a comparison group of employers that do not switch plans. I use a triple-difference design to estimate price changes for enrollees in markets with more hospital choices. Finally, I re-estimate models with hospital-fixed effects. DATA COLLECTION: From the HCCI sample, childbearing women enrolled in an employer-sponsored plan with at least 10 people. PRINCIPAL FINDINGS: Switching to an HDHP increases out-of-pocket cost $227 (p < 0.001; comparison group base $790) and has no meaningful effect on hospital-negotiated prices (-$26, p = 0.756; comparison group base $5821). HDHP switch is associated with a marginally statistically significant price increase in markets with three or fewer hospitals ($343, p = 0.096; comparison group base $5806) and, relative to those markets, with a price decrease in markets with more than three hospitals (-$512; p = 0.028). Predicted prices decrease from $5702 to $5551 after HDHP switch in markets with more than three hospitals due primarily to lower prices conditional on using the same hospital. CONCLUSIONS: Prices for childbirth in markets with more hospitals decrease after HDHP switch due to lower hospital prices for HDHPs relative to prices at those same hospitals for non-HDHPs. These results reinforce previous findings that HDHPs do not promote price shopping but suggest negotiated prices may be lower for HDHP enrollees.

Midwives' perspectives on person-centred maternity care in public hospitals in South-east Nigeria: A mixed-method study.

BACKGROUND: Person-centred maternity care (PCMC) is acknowledged as essential for achieving improved quality of care during labour and childbirth. Yet, evidence of healthcare providers' perspectives of person-centred maternity care is scarce in Nigeria. This study, therefore, examined the perceptions of midwives on person-centred maternity care (PCMC) in Enugu State, South-east Nigeria. MATERIALS AND METHODS: This study was conducted in seven public hospitals in Enugu metropolis, Enugu State, South-east Nigeria. A mixed-methods design, involving a cross-sectional survey and focus group discussions (FGDs) was used. All midwives (n = 201) working in the maternity sections of the selected hospitals were sampled. Data were collected from February to May 2019 using a self-administered, validated PCMC questionnaire. A sub-set of midwives (n = 56), purposively selected using maximum variation sampling, participated in the FGDs (n = 7). Quantitative data were entered, cleaned, and analysed with SPSS version 20 using descriptive and bivariate statistics and multivariate regression. Statistical significance was set at alpha 0.05 level. Qualitative data were analysed thematically. RESULTS: The mean age of midwives was 41.8 years ±9.6 years. About 53% of midwives have worked for ≥10 years, while 60% are junior midwives. Overall, the prevalence of low, medium, and high PCMC among midwives were 26%, 49% and 25%. The mean PCMC score was 54.06 (10.99). High perception of PCMC subscales ranged from 6.5% (dignity and respect) to 19% (supportive care). Midwives' perceived PCMC was not significantly related to any socio-demographic characteristics. Respectful care, empathetic caregiving, prompt initiation of care, paying attention to women, psychosocial support, trust, and altruism enhanced PCMC. In contrast, verbal and physical abuses were common but normalised. Midwives' weakest components of autonomy and communication were low involvement of women in decision about their care and choice of birthing position. Supportive care was constrained by restrictive policy on birth companion, poor working conditions, and cost of childbirth care. CONCLUSION: PCMC is inadequate in public hospitals as seen from midwives' perspectives. Demographic characteristics of midwives do not seem to play a significant role in midwives' delivery of PCMC. The study identified areas where midwives must build competencies to deliver PCMC.

Effects of the World Health Organization Safe Childbirth Checklist on Quality of Care and Birth Outcomes in Aceh, Indonesia: A Cluster-Randomized Clinical Trial.

Importance: To address major causes of perinatal and maternal mortality, the World Health Organization developed the Safe Childbirth Checklist (SCC), which to our knowledge has been rigorously evaluated only in combination with high-intensity coaching. Objective: To evaluate the effect of the SCC with medium-intensity coaching on health care workers' performance of essential birth practices. Design, Setting, and Participants: This cluster randomized clinical trial without blinding included 32 hospitals and community health centers in the province of Aceh, Indonesia (a medium-resource setting) that met the criterion of providing at least basic emergency obstetric and newborn care. Baseline data were collected from August to October 2016, and outcomes were measured from March to April 2017. Data were analyzed from January 2020 to October 2021. Interventions: After applying an optimization method, facilities were randomly assigned to the treatment or control group (16 facilities each). The SCC with 11 coaching visits was implemented during a 6-month period. Main Outcomes and Measures: For the primary outcome, clinical observers documented whether 36 essential birth practices were applied at treatment and control facilities at 1 or more of 4 pause points during the birthing process (admission to the hospital, just before pushing or cesarean delivery, soon after birth, and before hospital discharge). Probability models for binary outcome measures were estimated using ordinary least-squares regressions, complemented by Firth logit and complier average causal effect estimations. Results: Among the 32 facilities that participated in the trial, a significant increase of up to 41 percentage points was observed in the application of 5 of 36 essential birth practices in the 16 treatment facilities compared with the 16 control facilities, including communication of danger signs at admission (treatment: 136 of 155 births [88%]; control: 79 of 107 births [74%]), measurement of neonatal temperature (treatment: 9 of 31 births [29%]; control: 1 of 20 births [5%]), newborn feeding checks (treatment: 22 of 34 births [65%]; control: 5 of 21 births [24%]), and the rate of communication of danger signs to mothers and birth companions verbally (treatment: 30 of 36 births [83%]; control: 14 of 22 births [64%]) and in a written format (treatment: 3 of 24 births [13%]; control: 0 of 16 births [0%]). Conclusions and Relevance: In this cluster randomized clinical trial, health facilities that implemented the SCC with medium-intensity coaching had an increased rate of application for 5 of 36 essential birth practices compared with the control facilities. Medium-intensity coaching may not be sufficient to increase uptake of the SCC to a satisfying extent, but it may be worthwhile to assess a redesigned coaching approach prompting long-term behavioral change and, therefore, effectiveness. Trial Registration: isrctn.org Identifier: ISRCTN11041580.

Effect of decision to delivery interval on perinatal outcomes during emergency cesarean deliveries in Ethiopia: A prospective cohort study.

BACKGROUND: The National guidelines of most developed countries suggest a target of 30 minutes of the decision to delivery interval for emergency cesarean section. Such guidelines may not be feasible in poorly resourced countries and busy obstetric settings. It is generally accepted that the decision to delivery interval should be kept to the minimum time achievable to prevent adverse outcomes. Therefore, this study aimed to determine the average decision to delivery interval and its effect on perinatal outcomes in emergency cesarean section. METHODS: A prospective cohort study was conducted from May to July 2020 at Bahir Dar City Public Hospitals. A total of 182 participants were enrolled, and data were collected using a structured and pre-tested questionnaire. A systematic sampling technique was applied to select the study subjects. Data were cleaned and entered into Epi-Data version 4.6 and exported to SPSS version 25 software for analysis. Logistic regression analysis was performed to identify predictors of outcome variables, and variables with a p-value of <0.05 were considered statistically significant. RESULTS: The average decision to delivery interval was 43.73 ±10.55 minutes. Anesthesia time [AOR = 2.1, 95%CI = (1.3-8.4)], and category of emergency cesarean section [AOR = 3, 95% CI = (2.1-11.5)] were predictors of decision to delivery interval. The prolonged decision to delivery interval had a statistically significant association with composite adverse perinatal outcomes (odds ratio [OR] = 1.8, 95% confidence interval [CI] = (1.2-6.5). CONCLUSION: The average decision to delivery interval was longer than the recommended time. It should always be considered an important factor contributing to perinatal outcomes. Therefore, to prevent neonatal morbidity and mortality, a time-dependent action is needed.

Consistency and timeliness of intrapartum care interventions as predictors of intrapartum stillbirth in public health facilities of Addis Ababa, Ethiopia: a case-control study.

INTRODUCTION: approximately one-third of the global stillbirth burden occurs during intrapartum period. Intrapartum stillbirths occurring in the health facilities imply that a foetus was alive on admission to labour and had greater chances of survival with optimum obstetric care. Active monitoring and follow-up by skilled birth attendants becomes critical to determine the progress of labour and to decide any emergency obstetrical care actions. Timely monitoring of labour progress indicators including fetal heart rate (FHR), uterine contraction maternal vital signs, vaginal examination (VE) are vital in reducing intrapartum stillbirth. METHODS: a case-control study was conducted using primary data from chart review of medical records of women who experienced intrapartum stillbirth in 20 public health centres and 3 public hospitals of Addis Ababa between July 1st, 2010 to June 30th, 2015. Data were collected from charts of all cases of intrapartum stillbirths meeting the inclusion criteria and randomly selected charts of controls from each public health facility in 2: 1 control to case ratio. RESULTS: over 90% of both cases and controls received FHR monitoring care albeit the timing was substandard. More women in the live birth group than intrapartum stillbirth group received timely care related to uterine contraction (OR 2.42, 95% CI 1.77 - 3.30) and blood pressure monitoring (aOR 1.41, 95% CI 1.09 - 1.81). 1.2% and 0.3% of women in the intrapartum stillbirth and livebirth groups developed eclampsia respectively. CONCLUSION: substandard timing and application of labour monitoring interventions including FHR, uterine contraction can predict intrapartum stillbirth in public health facilities.

Coexistence and prevalence of obstetric interventions: an analysis based on the grade of membership.

BACKGROUND: Obstetric interventions performed during delivery do not reflect improvements in obstetric care. Several practices routinely performed during childbirth, without any scientific evidence or basis - such as Kristeller maneuver, routine episiotomy, and movement or feeding restriction - reflect a disrespectful assistance reality that, unfortunately, remains in place in Brazil. The aims of the current study are to assess the coexistence and prevalence of obstetric interventions in maternity hospitals in Belo Horizonte City, based on the Grade of Membership (GoM) method, as well as to investigate sociodemographic and obstetric factors associated with coexistence profiles generated by it. METHODS: Observational study, based on a cross-sectional design, carried out with data deriving from the study "Nascer em Belo Horizonte: Inquérito sobre o Parto e Nascimento" (Born in Belo Horizonte: Survey on Childbirth and Birth). The herein investigated interventions comprised practices that are clearly useful and should be encouraged; practices that are clearly harmful or ineffective and should be eliminated; and practices that are inappropriately used, in contrast to the ones recommended by the World Health Organization. The analyzed interventions comprised: providing food to parturient women, allowing them to have freedom to move, use of partogram, adopting non-pharmacological methods for pain relief, enema, perineal shaving, lying patients down for delivery, Kristeller maneuver, amniotomy, oxytocin infusion, analgesia and episiotomy. The current study has used GoM to identify the coexistence of the adopted obstetric interventions. Variables such as age, schooling, skin color, primigravida, place-of-delivery financing, number of prenatal consultations, gestational age at delivery, presence of obstetric nurse at delivery time, paid work and presence of companion during delivery were taken into consideration at the time to build patients' profile. RESULTS: Results have highlighted two antagonistic obstetric profiles, namely: profile 1 comprised parturient women who were offered diet, freedom to move, use of partogram, using non-pharmacological methods for pain relief, giving birth in lying position, patients who were not subjected to Kristeller maneuver, episiotomy or amniotomy, women did not receive oxytocin infusion, and analgesia using. Profile 2, in its turn, comprised parturient women who were not offered diet, who were not allowed to have freedom to move, as well as who did not use the partograph or who were subjected to non-pharmacological methods for pain relief. They were subjected to enema, perineal shaving, Kristeller maneuver, amniotomy and oxytocin infusion. In addition, they underwent analgesia and episiotomy. This outcome emphasizes the persistence of an obstetric care model that is not based on scientific evidence. Based on the analysis of factors that influenced the coexistence of obstetric interventions, the presence of obstetric nurses in the healthcare practice has reduced the likelihood of parturient women to belong to profile 2. In addition, childbirth events that took place in public institutions have reduced the likelihood of parturient women to belong to profile 2. CONCLUSION(S): Based on the analysis of factors that influenced the coexistence of obstetric interventions, financing the hospital for childbirth has increased the likelihood of parturient women to belong to profile 2. However, the likelihood of parturient women to belong to profile 2 has decreased when hospitals had an active obstetric nurse at the delivery room. The current study has contributed to discussions about obstetric interventions, as well as to improve childbirth assistance models. In addition, it has emphasized the need of developing strategies focused on adherence to, and implementation of, assistance models based on scientific evidence.

Modification of oxytocin use through a coaching-based intervention based on the WHO Safe Childbirth Checklist in Uttar Pradesh, India: a secondary analysis of a cluster randomised controlled trial.

OBJECTIVE: To understand the prevalence of intrapartum oxytocin use, assess associated perinatal and maternal outcomes, and evaluate the impact of a WHO Safe Childbirth Checklist intervention on oxytocin use at primary-level facilities in Uttar Pradesh, India. DESIGN: Secondary analysis of a cluster-randomised controlled trial. SETTING: Thirty Primary and Community public health facilities in Uttar Pradesh, India from 2014 to 2017. POPULATION: Women admitted to a study facility for childbirth at baseline, 2, 6 or 12 months after intervention initiation. METHODS: The BetterBirth intervention aimed to increase adherence to the WHO Safe Childbirth Checklist. We used Rao-Scott Chi-square tests to compare (1) timing of oxytocin use between study arms and (2) perinatal mortality and resuscitation of infants whose mothers received intrapartum oxytocin versus who did not. MAIN OUTCOME MEASURES: Intrapartum and postpartum oxytocin administration, perinatal mortality, use of neonatal bag and mask. RESULTS: We observed 5484 deliveries. At baseline, intrapartum oxytocin was administered to 78.2% of women. Two months after intervention initiation, intrapartum oxytocin (I) was administered to 32.1% of women compared with 70.6% in the control (C) (P < 0.01); this difference diminished after the end of the intervention (I = 48.2%, C = 74.7%, P = 0.03). Partograph use remained at <1% at all facilities. Resuscitation was performed on 7.5% of infants whose mother received intrapartum oxytocin versus 2.0% who did not (P < 0.0001). CONCLUSIONS: In this setting, intrapartum oxytocin use was high despite limited maternal/fetal monitoring or caesarean capability, and was associated with increased neonatal resuscitation. The BetterBirth intervention was successful at decreasing intrapartum oxytocin use. Ongoing support is needed to sustain these practices. TWEETABLE ABSTRACT: Coaching + WHO Safe Childbirth Checklist reduces intrapartum oxytocin use and need for newborn resuscitation.

Safe birth matters: facilitators and barriers to uptake of the WHO safe childbirth checklist tool in a Tanzania Regional Hospital.

BACKGROUND: The World Health Organization (WHO) developed the Safe Birth Checklist (SCC) to facilitate best practices in safe birthing practices. The SCC is utilizing existing evidence-based WHO guidelines and recommendations which has combined those into a single and practical bedside tool. The SCC is the first checklist-based intervention to target the prevention of maternal and neonatal deaths. OBJECTIVE: The objective of this project was to pilot-test the World Health Organization Safe Childbirth Checklist with Maternity Regional Hospital in, Tanzania. STUDY DESIGN AND METHODS: Retrospective analysis on 35 charts were completed to identify presence or absence of documentation aligned with evidenced based checklist items. Staff training, end user observations and focus group discussions were utilized to elicit feedback about the tool and the process. Descriptive statistics and manual content analysis were used to analyze the rate of uptake and ownership over the checklist. The Checklist is broken down into four sections or time points (that are considered natural pause points in the care of laboring women). The four different pause points are admission, delivery, post-partum, and discharge. RESULTS: We trained 26 participants out of 32 staff how to use the SCC. Delivery time point had the lowest at SCC completion rate at 39% compared to discharge having the highest completion rate at 93%. There was variation in completion rate of the checklist items at each time point. Checklist items at the beginning of each time point were completed between 94% and 100% of the time with the latter checklist list items completed between 29% and 57% of the time. CONCLUSION: This project was able to identify facilitators and potential barriers to the successful uptake of the Safe Childbirth Checklist in Shinyanga Regional Hospital. Based on these findings, the MOH have opportunities to utilize those findings in the scale-up of the implementation of the checklist and future evaluation activities.