The buck stops here: midwives and maternity care in rural Scotland

Objective

to explore and understand what it means to provide midwifery care in remote and rural Scotland.

Design

qualitative interviews with 72 staff from 10 maternity units, analysed via a case study approach.

Setting

remote and rural areas of Scotland.

Participants

predominantly midwives, with some additional interviews with paramedics, general surgeons, anaesthetists and GPs.

Findings

remote and rural maternity care includes a range of settings and models of care. However, the impact of rural geographies on decision-making and risk assessment is common to all settings. Making decisions and dealing with the implications of these decisions is, in many cases, done without onsite specialist support. This has implications for the skills and competencies that are needed to practice midwifery in remote and rural settings. Whereas most rural midwives reported that their skills in risk assessment and decisions to transfer were well developed and appropriate to practising in their particular settings, they perceived these decisions to be under scrutiny by urban-based colleagues and felt the need to stress their competence in the face of what they imagined to be stereotypes of rural incompetence.

Conclusions

this study shows that skills in risk assessment and decision-making are central to high quality remote and rural midwifery care. However, linked to different perspectives on care, there is a risk that these skills can be undermined by contact with colleagues in large urban units, particularly when staff do not know each other well. There is a need to develop a professional understanding between midwives in different locations.

Implications for practice

it is important for the good working relationships between urban and rural maternity units that all midwives understand the importance of contextual knowledge in both decisions to transfer from rural locations and the position of midwives in receiving units. Multiprofessional CPD courses have been effective in bringing together teams around obstetric emergencies; we suggest that a similar format may be required in considering issues of transfer.     

Duration of bladder catheterization after surgery for obstetric fistula

Objective

To compare the surgical outcome at discharge and at 6-months follow up in patients who underwent repair of obstetric fistulae with postoperative bladder catheterization for 10, 12, or 14 days.

Methods

A retrospective study of 212 obstetric fistula patients who underwent repair with postoperative bladder catheterization for 10 days (group 1), 12 days (group 2), and 14 days (group 3) at the Bahir Dar Hamlin Fistula Center in Ethiopia. Fistulas were classified according to Goh's system.

Results

There were 68 women (32%) in group 1, 62 women (29%) in group 2, and 82 women (39%) in group 3. There was a significant difference in the extent of urethral involvement, fistula size, and degree of vaginal scarring among the 3 groups, with the more extensively damaged patients catheterized for longer. Breakdown of repair was seen in 1.5% of patients in group 1, none in group 2, and 2% in group 3 (P = 0.47).

Conclusion

Postoperative catheterization for 10 days may be sufficient for management of less complicated obstetric vesicovaginal fistulae.     

After praise and encouragement: Emotional support strategies used by birth doulas in the USA and Canada

Objective

to describe in detail the emotional support techniques employed by birth doulas during labour.

Design

grounded theory methodology was utilised in collecting and analysing interviews given by doulas and mothers who had doula care. By using both informants, a clearer picture of what constitutes emotional support by doulas emerged.

Participants

10 mothers from three different states in the Midwestern USA and 30 doulas from 10 different states and two Canadian provinces were interviewed. Two doulas worked in hospital-based programmes whereas the others had independent practices. Doulas usually attended births in hospitals where medical attendants spent little focused time with the mother.

Findings

nine different strategies were distinguished. Four strategies (reassurance, encouragement, praise, explaining) were similar to those attributed to nurses in published research. Five were original and described as only being used by doulas (mirroring, acceptance, reinforcing, reframing, debriefing).

Conclusions

emotional support by professional birth doulas is more complex and sophisticated than previously surmised. Mothers experienced these strategies as extremely meaningful and significant with their ability to cope and influencing the course of their labour.

Implications for practice

the doula’s role in providing emotional support is distinct from the obstetric nurse and midwife. Professional doulas utilise intricate and complex emotional support skills when providing continuous support for women in labour. Application of these skills may provide an explanation for the positive ‘doula effect’ on obstetric and neonatal outcomes in certain settings.     

A national review of cesarean delivery in Ethiopia

Objective

To describe Ethiopian national population-based and institutional cesarean delivery rates by sector, and to describe indications for cesarean delivery, fetal and maternal outcomes, and aspects of quality of care.

Methods

The data source was the national baseline assessment of emergency obstetric and newborn care—a cross-sectional, facility-based survey of 797 facilities. Two instruments were used to collect the data for the present paper: a retrospective record review of 267 cesarean deliveries based on the last 3 performed in each facility; and a 12-month summary of each facility's statistics on vaginal and abdominal deliveries.

Results

The national population-based cesarean delivery rate was 0.6%, with regional rates varying from 0.2% to 9%. The overall institutional rate was 18%, which varied between 46% in the private for- profit sector and 15% in the public sector. Maternal indications accounted for 66% of the cesareans reviewed, and fetal indications for 34%. Three-quarters of the cesareans were recorded as emergencies, but only 12% of these had their labor monitored with a partograph. The interval between decision and delivery was within 30 minutes for 36% of the women, 31-60 minutes for 23%, and more than 5 hours for 19%. Antibiotics were given in 94% of the reviewed cases; nevertheless, 12% of the cases reported wound infection. There were 2 maternal deaths and 14% of the newborns were stillbirths or died shortly after birth.

Conclusion

The study showed little progress in the proportion of all births delivered by cesarean and a high rate of cesarean among women attended in the private sector—indicating a need to monitor the appropriateness of obstetric care in all sectors and to increase access in rural areas. Clinical management protocols for obstetric and newborn care are needed, and audits of cesareans should be performed at all institutions, especially in the private sector. The importance of improving record keeping is crucial for informed local decision-making.     

Impact of placenta previa on obstetric outcome

Objective

To determine the maternal and perinatal outcome for different types of placenta previa (PP).

Methods

A retrospective review of 132 singleton pregnancies with PP. Outcome measures, including the incidence of obstetric hysterectomy, the neonatal Apgar score, and the neonatal weight, were evaluated by logistic regression analysis.

Results

The incidence of PP was 1.0%. Of the women with PP, 51.5% had complete PP, 20.5% had incomplete PP, 5.3% had marginal PP, and 22.7% had a low-lying placenta. Most (93.9%) women were delivered by cesarean delivery. In total, 19.7% women underwent obstetric hysterectomy; of these, 92.3% had complete PP. Mothers with 2 or more previous cesarean deliveries had an increased risk for obstetric hysterectomy (P < 0.01). The gestational age at delivery was a significant linear predictor of the 5-minute Apgar score. Mothers with incomplete PP delivered neonates with lower Apgar scores than did mothers with complete PP.

Conclusion

A history of multiple cesarean deliveries increased the risk for obstetric hysterectomy in women with PP. The type of PP had no effect on maternal and neonatal outcome, with exception of the fact that neonates in the incomplete PP group had lower Apgar scores than neonates in the complete PP group.     

Risk factors for obstetric fistula in the Far North Province of Cameroon

Objective

To describe the circumstances of occurrence and identify potential risk factors for obstetric fistula in northern Cameroon.

Methods

A case series study of 42 obstetric fistula patients seeking services at the Provincial Hospital of Maroua, Cameroon, between May 2005 and August 2007. Structured interviews were conducted prior to surgical intervention.

Results

Among obstetric fistula patients, 60% had lived with obstetric fistula for more than 5 years at the time of surgery. Eighty-one percent of patients had received no formal education and 86% were teenagers at their first delivery. Regarding the pregnancy and delivery preceding the occurrence of the fistula, 50% of women reported that they had received no prenatal care and 76% were in labor for more than 12 hours. The majority (83%) of women delivered a stillborn baby.

Conclusions

Obstetric fistula patients in the Far North Province of Cameroon had a low level of education, were married at a young age, and had poor access to quality maternal healthcare services.     

Amniocentesis genéticas durante los últimos 6 años en nuestro hospital

Introduction

Identification of fetal congenital chromosomal abnormalities is undoubtedly one of the main challenges faced by obstetricians involved in the prenatal diagnosis of congenital anomalies.

Objective

To evaluate the diagnostic yield of genetic amniocentesis in our hospital and its associated complications.

Patients And Methods

We performed a retrospective analysis of all genetic amniocenteses performed in our hospital in the last 6 years, focusing on diagnostic yield, the most common associated complications, and the indications for this procedure. We also reviewed the various population-based screening programs currently applied.

Results

The main indication for amniocentesis was maternal age-associated risk. A total of 2.161% of procedures led to diagnosis of chromosomal abnormalities, with a complications rate of 1.028%.

Conclusion

Although our results are similar to those reported in other published series, current screening strategies should be revised, mainly in older pregnant women.     

Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in a representative cohort of Spanish women of fertile age

Objective

To assess the prevalence of premenstrual symptoms, premenstrual syndrome and premenstrual dysphoric disorder in a cohort of women of fertile age representative of the general Spanish population.

Study design

During the period between November 27th and December 22nd, 2008, a cross-sectional nationwide survey was conducted among a cohort of Spanish women aged between 15 and 49 years. Participants were personally interviewed at home and completed the premenstrual symptoms screening tool.

Results

Of the 2108 participants, 1554 women (73.7%) complained of some of the premenstrual symptoms during the last 12 menstrual cycles. A total of 1415 (91%) women presented isolated symptoms and 139 (8.9%) a moderate/severe premenstrual syndrome. Twenty-four (1.1%) women fulfilled criteria for a diagnosis of premenstrual dysphoric disorder.

Conclusion

The prevalence of premenstrual symptoms (73.7%) and premenstrual dysphoric disorder (1.1%) in Spanish women aged between 15 and 49 years is similar to that reported in other Western countries. Only women with moderate or severe premenstrual syndrome or premenstrual dysphoric disorder, however, had daily life activities significantly impaired by premenstrual symptoms.     

Papel de p16 en lesiones preinvasivas e invasivas de cáncer de cuello uterino. Aplicación de la técnica a citología convencional

Introduction

Detection of p16 expression by immunohistochemistry and immunocytochemistry is a good standard for the identification of high-grade cervical epithelial lesions and low-grade lesions with DNA HPV viral integration (with a tendency for progression).

Material and methods

We evaluated p16 expression in 58 HPV-positive cervical biopsies and 53 conventional cytological samples that tested HPV-positive with immunohistochemical and immunocytochemical techniques.

Results

All high-grade lesions were positive for p16 while only some of the low-grade lesions were positive. The results obtained in histological samples could be extrapolated to cytological samples from the same patients.

Conclusions

p16 expression in conventional cytology provides similar results to those in histological samples.     

Indicators for availability, utilization, and quality of emergency obstetric care in Ethiopia, 2008

Objective

To report on the availability and quality of emergency obstetric and newborn care (EmONC) in Ethiopia.

Methods

All licensed hospitals and health centers were visited and standard questionnaires were administered. In addition, a nonrandom systematic sample was taken of recent cesarean deliveries, partographs, and maternal deaths—and these cases were systematically reviewed. Health facilities were geocoded using geographic positioning system devices.

Results

Too few facilities provided EmONC to meet the UN standards of 5 per 500 000 population, both nationally and in all but 2 regions. Only 7% of deliveries took place in institutions of any type, and only 3% in facilities that routinely provided all the signal functions. Only 6% of women with obstetric complications were treated in any health facility, half of whom were treated in fully functional EmONC facilities. Nationwide, 0.6% of expected deliveries were by cesarean. The mortality rate for women with serious obstetric complications (case fatality rate) was 2%. The cause of death was unknown in 10% of cases, and 21% were due to indirect causes (primarily malaria, anemia, and HIV-related).

Conclusion

None of the indicators met UN standards. Ethiopia faces many challenges—not least geography—with regard to improving EmONC. Nevertheless, the government places high priority on improvement and has taken (and will continue to take) action to achieve Millennium Development Goals 4 and 5. This comprehensive survey serves both as a road map for planning strategies for improvement and as a baseline for measuring the impact of interventions.     

Obstetricians' opinions and attitudes toward maternal refusal of recommended cesarean delivery in Nigeria

Objective

To assess the opinions and attitudes of Nigerian obstetricians toward women's refusal of cesarean delivery.

Method

We used a questionnaire with 5 clinical scenarios drawn from published cases in which Nigerian women refused to undergo a recommended cesarean delivery.

Results

Most obstetricians (84.8%) advocated continuous counseling of these women but, from their response to the scenarios, few (13.7%-16.1%) would actually do so. Insufficient facilities and poor logistics for emergency obstetric care were their stated major reason for not respecting maternal choices in situations where vaginal delivery could have been given a chance.

Conclusion

The possibility of providing emergency obstetric care would remove many indications for cesarean delivery from the list of absolute indications in Nigeria; and management guidelines would protect obstetricians in the event of litigation, and improve their acceptance and respect of maternal choice.     

Obstetric fistula in low-income countries

Objective

To identify, survey, and systematically review the current knowledge regarding obstetric fistula as a public health problem in low-income countries from the peer-reviewed literature.

Methods

The Medline and Science Citation Index databases were searched to identify public health articles on obstetric fistula in low-income countries. Quantitative evidence-based papers were reviewed.

Results

Thirty-three articles met the criteria for inclusion: 18 hospital-based reviews; 6 on risk factors/prevention; 4 on prevalence/incidence measurement; 3 on consequences of obstetric fistula; and 2 on community-based assessments.

Conclusion

Obstetric fistula has received increased international attention as a public health problem, but reliable research on the burden of disease and interventions is lacking.     

Tratamiento laparoscópico del quiste dermoide de ovario. Factores asociados a la rotura intraoperatoria, trascendencia clínica y resultados

Objective

To analyze the surgical characteristics of laparoscopic treatment of dermoid cyst and the factors associated with intraoperative spillage and its clinical importance.

Material and methods

A retrospective research was performed of 131 dermoid cysts treated by laparoscopy at the Virgen de las Nieves University Hospital from January 2000 to December 2008.

Results

The mean age of the patients was 32.4 years. The mean size of the cysts was 63.8 mm. In 62.6% of the patients, conservative surgery (cystectomy) was feasible. Only two patients needed reintervention due to bleeding complications. The mean length of hospital stay was 1.6 days. Intraoperative spillage was more common when cystectomy was performed. There were no cases of peritonitis.

Conclusions

Laparoscopic surgery is the first treatment option in the management of ovarian dermoid cysts. There are few complications and healing is rapid. Spillage is usually clinically unimportant.     

Cesarean delivery-related fistulae in the Democratic Republic of Congo

Objective

To compare the characteristics of urogenital fistulae after cesarean delivery with those after spontaneous vaginal delivery.

Methods

A retrospective analysis of hospital records of 597 consecutive patients with a urogenital fistula who received treatment at Panzi Hospital, Bukavu, Democratic Republic of Congo, during 2005-2007.

Results

Of 576 women with an obstetric fistula, 229 (40%) had had a cesarean delivery; 55 (24%) of the 229 fistulae were considered to be iatrogenic. The distribution of risk factors (age, stature, parity, and labor duration) was similar to that among 226 women with a spontaneous vaginal delivery, but the odds ratios for having a ureterovaginal or a vesicouterine fistula were 11.9 (95% confidence interval [CI] 2.8-51.2) and 9.5 (95% CI 2.8-31.9), respectively. Vesicovaginal fistulae with cervical involvement were also significantly more frequent in the cesarean delivery group. The fistulae in this group had less surrounding fibrosis and there was less treatment delay. Stillbirth rates were 87% (cesarean delivery) and 95% (spontaneous vaginal delivery).

Conclusion

The data indicate that cesarean delivery-related fistulae are a separate clinical entity. Focus on this condition is important for fistula prevention and provision of adequate obstetric care, particularly for training in surgery and alternative delivery methods.     

Factors associated with maternal death in women admitted to an intensive care unit with severe maternal morbidity

Objective

To identify factors associated with maternal death among women with severe maternal morbidity.

Methods

A retrospective study of 673 women admitted to an obstetric intensive care unit was undertaken. The odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for selected characteristics. The maternal mortality and severe maternal morbidity ratios were determined for groups of complications according to outcome (death or survival).

Results

The risk of maternal death was higher among adolescents (OR 3.3; 95% CI, 1-9.7) and patients referred from other hospitals (OR 9.8; 95% CI, 2.7-53.3). The severe maternal morbidity ratio was 46.6 per 1000 deliveries and the mortality:morbidity ratio 1:37.4. Obstetric complications led to 65.8% of admissions and 50% of maternal deaths. The number of interventions/procedures and total maximum sequential organ failure assessment score were higher in cases of death.

Conclusion

The strong association between interhospital transfer and maternal death suggests delays in diagnosis, management, and referral. Adopting organ dysfunction-based criteria may contribute toward identifying the most severe cases.     

Where there is no anesthetist - increasing capacity for emergency obstetric care in rural India: An evaluation of a pilot program to train general doctors

Objective

The lack of anesthesia providers in rural public sector hospitals is a significant barrier to providing emergency obstetric care. In 2006, the state of Gujarat initiated the Life Saving Anesthetic Skills (LSAS) for Emergency Obstetric Care (EmOC) training program for medical offers (MOs). We evaluated the trained MOs’ experience of the program, and identified factors leading to post-training performance.

Methods

The sample was chosen to equally represent performing and nonperforming LSAS-trained MOs using purposive sampling qualitative interviews with trainees across Gujarat (n = 14). Data on facility preparedness and monthly case load were also collected.

Results

Being posted with a specialist anesthesiologist and with a cooperative EmOC provider increased the likelihood that the MOs would provide anesthesia. MOs who did not provide anesthesia were more likely to have been posted with a nonperforming or uncooperative EmOC provider and were more likely to have low confidence in their ability to provide anesthesia. Facilities were found to be under prepared to tackle emergency obstetric procedures.

Conclusion

Program managers should consider extending the duration of the program and placing more emphasis on practical training. Posting doctors with cooperative and performing EmOC providers will significantly improve the effectiveness of the program. A separate team of program managers who plan, monitor, and solve the problems reported by the trained MOs would further enhance the success of scaling up the training program.     

Emergency obstetric surgery by non-physician clinicians in Tanzania

Objective

To calculate the met need for comprehensive emergency obstetric care (CEmOC) in 2 Tanzanian regions (Mwanza and Kigoma) and to document the contribution of non-physician clinicians (assistant medical officers [AMOs]) and medical officers (MOs) with regard to meeting the need for CEmOC.

Methods

All hospitals in the 2 regions were visited to determine the proportion of major obstetric interventions performed by AMOs and MOs. All deliveries (n = 38 758) in these hospitals in 2003 were reviewed. The estimated met need for emergency obstetric care (EmOC) was calculated using UN process indicators, as was the contribution to that attainment by AMOs. Hospital case fatality rates were also determined.

Results

Estimated met need was 35% in Mwanza and 23% in Kigoma. AMOs operating independently performed most major obstetric surgery. Outside of the single university hospital, AMOs performed 85% of cesareans and high proportions of other obstetric surgeries. The case fatality rate was 2.0% in Mwanza and 1.2% in Kigoma.

Conclusion

AMOs carried most of the burden of life-saving EmOC—particularly cesarean deliveries—in the regions investigated. Case fatality was close to the 1% target set by the UN process indicators, but met need was far below the goal of 100%.     

Disease burden due to pre-eclampsia/eclampsia and the Ethiopian health system's response

Objective

To assess the maternal disease burden due to pre-eclampsia/eclampsia in Ethiopia and the national health system's readiness to respond to the needs of women with pre-eclampsia/eclampsia.

Methods

The national emergency obstetric and newborn care (EmONC) assessment entailed collecting information from 112 hospitals and 685 health centers in Ethiopia, focusing on their infrastructure, the services they provided, human resources, equipment and supplies, case load, and mortality due to pre-eclampsia/eclampsia.

Results

Pre-eclampsia/eclampsia complicated 1.2% of all institutional deliveries. Given the low institutional delivery rate and an expected incidence of 2%-8% of all deliveries, this implies that only a small fraction (3.8%) of all women with pre-eclampsia/eclampsia received care at health facilities. 11% of all maternal deaths and 16% of direct maternal deaths were due to this obstetric complication. The cause-specific case fatality rate was high (3.6%). Availability of urine test strips, anticonvulsants, antihypertensives, and actual service provision to treat these diseases was limited, especially at health centers.

Conclusion

The salutary effects of the national EmONC assessment were immediate, as evidenced by how quickly the release of the Ethiopian report led to important national efforts to improve maternal and newborn health. Expansion of health services should be augmented with periodic assessments of logistics and quality-related issues to assure functioning facilities for women accessing obstetric services.