Risk factors and perinatal outcomes associated with idiopathic small for gestational age Taiwanese newborns

Objective

To determine risk factors and perinatal outcomes associated with small for gestational age (SGA) neonates among healthy pregnant women.

Methods

A retrospective cohort study was conducted of 49 945 women who gave birth at Chang Gung Memorial Hospital, Taipei, Taiwan, after 24 weeks of pregnancy. Idiopathic SGA newborns (n = 3398) were characterized by a birth weight below the 10th percentile for mean weight corrected for GA and fetal sex.

Results

Risk factors for idiopathic SGA newborns included hypercoiling of the umbilical cord (adjusted odds ratio [aOR], 3.3; 95% confidence interval [CI], 1.6–7.0); prior fetal death (aOR, 2.8; 95% CI, 2.0–3.9); primiparity (aOR, 1.5; 95% CI, 1.4–1.7); adolescent pregnancy (aOR, 1.5; 95% CI, 1.2–2.0), low prepregnancy weight (aOR, 1.6; 95% CI, 1.5–1.8), low prepregnancy body mass index (aOR, 1.1; 95% CI, 1.0–1.3); short stature (aOR, 1.3; 95% CI, 1.1–1.4); and entangled umbilical cord (aOR, 1.1; 95% CI, 1.0–1.3). Idiopathic SGA newborns correlated with increased risk of adverse perinatal outcomes, including fetal death, low Apgar scores, oligohydramnios, placental abruption, and admission to the neonatal intensive care unit.

Conclusion

Some risk factors for idiopathic SGA newborns were modifiable, suggesting potential implications for public health.     

Comparison of outcomes of perinatal care in Slovakia and the UK

Objective

To investigate whether there are differences in maternal and perinatal outcomes between Slovakia and the UK, and whether any observed variations can be attributed to differences in perinatal care.

Methods

Data on outcomes of perinatal care in Slovakia and the UK between 2006 and 2010 were compared. Perinatal mortality figures included stillbirths weighing 1000 g or more and early neonatal deaths.

Results

In Slovakia, the perinatal mortality rate was significantly higher than that in the UK (RR 1.12; 95% CI, 1.06–1.18). Cesarean delivery was significantly more frequent in Slovakia (RR 1.05; 95% CI, 1.05–1.06); instrumental vaginal delivery was less frequent (ventouse delivery, RR 0.20; 95% CI, 0.19–0.21; forceps delivery, RR 0.09; 95% CI, 0.09–0.10). Episiotomy and peripartum hysterectomy were performed more often in Slovakia (episiotomy, RR 4.10; 95% CI, 4.07–4.12; peripartum hysterectomy, RR 2.02; 95% CI 1.65–2.47). The incidence of eclampsia was significantly higher in Slovakia (RR 1.60; 95% CI, 1.26–2.04). There were no significant differences in the rates of maternal death.

Conclusion

Perinatal care outcomes and intervention rates differ between Slovakia and UK. This may be explained by differences in outcome definitions, perinatal care, and official encouragement of medical complaints.     

Comparison of outcomes between operative vaginal deliveries and spontaneous vaginal deliveries in southeast Nigeria

Objective

To evaluate the incidence of, indications for, and outcome of operative vaginal deliveries compared with spontaneous vaginal deliveries in southeast Nigeria.

Methods

A retrospective cohort study was conducted involving cases of operative vaginal delivery performed at Ebonyi State University Teaching Hospital over a 10-year period. Data on the procedures were abstracted from the operation notes of the medical records of parturients.

Results

An incidence of 4.7% (n = 461) was recorded. The most common indications for vacuum and forceps delivery were prolonged second stage of labor (44.9%) and poor maternal effort (27.8%). The only indication for destructive operation was intrauterine fetal death (3.7%). The risk ratio (RR) for hemorrhage/vulvar hematoma was 1.14 (95% confidence interval [CI], 0.53–2.48) for vacuum-assisted delivery and 5.49 (95% CI, 0.82–36.64) for forceps delivery. The RR for genital laceration was 1.21 (95% CI, 0.44–3.30) for vacuum-assisted delivery and 9.41 (95% CI, 1.33–66.65) for forceps delivery. The risk of fetal scalp bruises and caput succedaneum was higher for operative vaginal delivery than for spontaneous vaginal delivery, with no significant difference in maternal morbidity. The perinatal mortality rate was 0.9 per 1000 live births.

Conclusion

Operative vaginal delivery by experienced healthcare providers is associated with good obstetric outcomes with minimal risk.     

Association between delivery of a small-for-gestational-age neonate and long-term maternal cardiovascular morbidity

Objective

To investigate whether delivering a small-for-gestational-age (SGA) newborn is a risk factor for subsequent long-term maternal cardiovascular morbidity.

Methods

Data were analyzed from consecutive pregnant women who delivered at Soroka University Medical Center, Beer-Sheva, Israel, between 1988 and 1999, and were followed-up retrospectively until 2010. Long-term cardiovascular morbidity was compared among women with and without SGA neonates.

Results

During the study period, 47 612 deliveries met the inclusion criteria, and 4411 (9.3%) women delivered an SGA neonate. Delivery of an SGA neonate was a risk factor for long-term complex cardiovascular events, including congestive heart failure, hypertensive heart and kidney disease, and acute cor pulmonale (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3–4.4; P = 0.006); and long-term cardiovascular mortality (OR, 3.4; 95% CI, 1.5–7.6; P = 0.006). Women who delivered an SGA neonate had a significantly higher risk for cardiovascular mortality during the follow-up period (Kaplan–Meier survival analysis, P = 0.002). Delivery of an SGA neonate remained an independent risk factor for long-term maternal cardiovascular mortality (Cox multivariable regression: adjusted hazard ratio, 3.5; 95% CI, 1.5–8.2; P = 0.004).

Conclusion

Delivery of an SGA neonate is an independent risk factor for long-term cardiovascular morbidity in a follow-up period of more than 10 years.     

Bilirubin influences the clinical presentation of pre-eclampsia

Objectives

Pre-eclampsia is a placental, inflammatory disease modified by maternal anti-oxidant status to give a syndrome. In its most severe forms pre-eclampsia is followed by maternal and neonatal mortality and morbidity. Bilirubin is a known antioxidant and as such is associated with a reduced risk of cardiovascular and respiratory disease. Hence we aimed to find an association between maternal bilirubin levels and the clinical severity of the disease.

Study design

A retrospective observational study of 50,712 pregnancies, 925 of which had pre-eclampsia (1999–2010), to examine the association between bilirubin level and perinatal outcome.

Results

In women with pre-eclampsia, those with bilirubin levels in the lowest quintile were more likely to require caesarean section (p = 0.001, aOR 2.59 (1.52–5.72)). The lowest quintile of bilirubin levels is associated with an increased risk of poor maternal (p = 0.002, aOR 3.52 (95%CI 1.6–7.7)) and infant/fetal (p = 0.001, OR = 3.05 (95%CI = 1.63–5.72)) outcome.

Conclusions

Low levels of bilirubin were associated with poor maternal and infant outcomes in women diagnosed with pre-eclampsia. Bilirubin may act as an anti-oxidant in this condition and thus modify the disease.     

Pilot community-mobilization program reduces maternal and perinatal mortality and prevents obstetric fistula in Niger

Objective

To assess the impact of a pilot community-mobilization program on maternal and perinatal mortality and obstetric fistula in Niger.

Methods

In the program, village volunteers identify and evacuate women with protracted labor, provide education, and collect data on pregnancies, births, and deaths. These data were used to calculate the reduction in maternal mortality, perinatal mortality, and obstetric fistula in the program area from July 2008 to June 2011.

Results

The birth-related maternal mortality fell by 73.0% between years 1 and 3 (P < 0.001), from 630 (95% confidence interval [CI] 448–861) to 170 (95% CI 85–305) deaths per 100 000 births. Early perinatal mortality fell by 61.5% (P < 0.001), from 35 (95% CI 31–40) to 13 (95% CI 10–16) deaths per 1000 births. No deaths due to obstructed labor were reported after the lead-in period (February to June 2008). Seven cases of community-acquired fistula were reported between February 2008 and July 2009; from August 2009 to June 2011 (23 months; 12 254 births), no cases were recorded.

Conclusion

Community mobilization helped to prevent obstetric fistula and birth-related deaths of women and infants in a large, remote, resource-poor area.     

Factors associated with maternal intrapartum transfers from a freestanding birth centre in São Paulo,Brazil: A case control study

Objectives

to identify factors associated with maternal intrapartum transfer from a freestanding birth centre to hospital.

Design

case-control study with retrospective data collection.

Participants and settings

cases included all 111 women transferred from a freestanding birth centre in Sao Paulo to the referral hospital, from March 2002 to December 2009. The controls were 456 women who gave birth in the birth centre during the same period who were not transferred, randomly selected with four controls for each case.

Methods

data were obtained from maternal records. Factors associated with maternal intrapartum transfers were initially analysed using a χ² test of association. Variables with p<0.20 were then included in multivariate analyses. A multiple logistic regression model was built using stepwise forward selection; variables which reached statistical significance at p<0.05 were considered to be independently associated with maternal transfer.

Findings

during the study data collection period, 111 (4%) of 2,736 women admitted to the centre were transferred intrapartum. Variables identified as independently associated factors for intrapartum transfer included nulliparity (OR 5.1, 95% CI 2.7–9.8), maternal age ≥35 years (OR 5.4, 95% CI 2.1–13.4), not having a partner (OR 2.8, 95% CI 1.5–5.3), cervical dilation ≤3 cm on admission to the birth centre (OR 1.9, 95% CI 1.1–3.2) and between 5 and 12 antenatal appointments at the birth centre (OR 3.8, 95% CI 1.9–7.5). In contrast, a low correlation between fundal height and pregnancy gestation (OR 0.3, 95% CI 0.2–0.6) appeared to be protective against transfer.

Conclusions and implications for practice

identifying factors associated with maternal intrapartum transfer could support decision making by women considering options for place of birth, and support the content of appropriate information about criteria for admission to a birth centre. Findings add to the evidence base to support identification of women in early labour who may experience later complications and could support timely implementation of appropriate interventions associated with reducing transfer rates.     

Estimation of maternal and neonatal mortality at the subnational level in Liberia

Objective

To establish representative local-area baseline estimates of maternal and neonatal mortality using a novel adjusted sisterhood method.

Methods

The status of maternal and neonatal health in Bomi County, Liberia, was investigated in June 2013 using a population-based survey (n = 1985). The standard direct sisterhood method was modified to account for place and time of maternal death to enable calculation of subnational estimates.

Results

The modified method of measuring maternal mortality successfully enabled the calculation of area-specific estimates. Of 71 reported deaths of sisters, 18 (25.4%) were due to pregnancy-related causes and had occurred in the past 3 years in Bomi County. The estimated maternal mortality ratio was 890 maternal deaths for every 100 000 live births (95% CI, 497–1301]. The neonatal mortality rate was estimated to be 47 deaths for every 1000 live births (95% CI, 42–52). In total, 322 (16.9%) of 1900 women with accurate age data reported having had a stillbirth.

Conclusion

The modified direct sisterhood method may be useful to other countries seeking a more regionally nuanced understanding of areas in which neonatal and maternal mortality levels still need to be reduced to meet Millennium Development Goals.     

A comparison of trends in cesarean delivery in Paraguay between 1995 and 2008

Objective

To identify maternal factors associated with the rise in the cesarean delivery rate in Paraguay.

Methods

Retrospective analysis of the 1995 and the 2008 National Survey on Demographic and Sexual and Reproductive Health data using multivariable logistic regression.

Results

In 2008, 1094 (37.3%) deliveries were cesarean compared with 781 (19.3%) in 1995. Home births had decreased by 72.9%, accounting for 33.3% of the change in the proportion of cesarean deliveries. Private facilities were associated with an increased odds ratio of cesarean delivery of 2.60 (95% confidence interval [CI], 2.02–3.34) and 4.89 (95% CI, 3.67–6.51) in 1995 and 2008, respectively, and accounted for 32.8% of the increase in cesarean deliveries between 1995 and 2008. Cesarean delivery was also associated with a prior cesarean, insurance status, and maternal higher educational and economic status.

Conclusion

Between 1995 and 2008 the cesarean delivery rate in Paraguay almost doubled. More than one-third of deliveries were cesarean. Shifts toward facility- (particularly private) based deliveries and repeat cesarean for women with a previous cesarean influenced this increase. Practice guidelines, regulation, and oversight of facilities, along with education and information for pregnant women, are needed to curb unnecessary and potentially harmful surgical delivery interventions.     

Influence of mode of delivery on neonatal mortality and morbidity in spontaneous preterm breech delivery

Objective

To study the association between mode of delivery and neonatal outcome in singleton pregnancy with breech presentation and preterm birth, due to premature labour (PTL) and/or preterm premature rupture of the membranes (pPROM).

Design and methods

Information on preterm (gestational week 25–36) singleton births in breech presentation in Sweden during 1990–2002 was obtained from the Swedish Medical Birth Registry and the Swedish Hospital Discharge Registry. The study groups included 1975 caesarean and 699 vaginal deliveries with a diagnosis of PTL or pPROM, without pregnancy complications implying a high risk of fetal compromise. The rates of infant respiratory distress syndrome (IRDS), intraventricular haemorrhage (IVH), low Apgar scores, and neonatal deaths were compared between infants delivered vaginally and by caesarean section. Odds ratios were calculated with adjustment for gestational age, year of birth, maternal age and parity.

Results

The risk of neonatal death and the risk of an Apgar score below 5 min postnatally were both lower after caesarean delivery (OR 0.4; 95% CI 0.2–0.7, and OR 0.4; 95% CI 0.3–0.7, respectively), whereas the risk of IRDS was increased (OR 2.1; 95% CI 1.4–3.2). A diagnosis of IRDS was not associated with mortality (OR 0.8; 95% CI 0.5–1.5). IVH was not associated with mode of delivery (OR 1.2; 95% CI 0.5–2.8).

Conclusion

The lower neonatal mortality after CS supports a policy of caesarean delivery of the preterm breech.     

Fetal and infant health outcomes among immigrant mothers in Flanders,Belgium

Objective

To compare fetal and infant mortality between immigrant and native-born mothers in Flanders, Belgium.

Methods

In a population-based study, data from 326 166 neonatal deliveries, collected by the Study Center for Perinatal Epidemiology and the Belgian Civil Birth Registration system between January 2004 and December 2008, were analyzed. Immigrant mothers were defined as women born in any country other than Belgium, and were grouped by country of origin according to the World Bank Atlas definition of low-, middle-, and high-income countries. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated to evaluate the association between immigration and fetal/infant outcome.

Results

In univariate analysis, fetal and infant mortality rates were significantly higher among immigrants than among native-born mothers (fetal: crude OR, 1.50; 95% CI, 1.29–1.75; infant: crude OR, 1.47; 95% CI, 1.29–1.67). Fetal/infant death rates were highest among mothers originating from low-income countries. In multivariate analysis, however, most differences became non-significant: only the early neonatal death rate remained significantly higher (adjusted OR, 1.30; 95% CI, 1.06–1.60), whereas the fetal death rate appeared lower (adjusted OR, 0.67; 95% CI, 0.57–0.80), among immigrant mothers.

Conclusion

After adjustment for relevant characteristics, fetal/infant mortality was comparable between immigrant women and native-born women in Flanders.     

Risk factors for severe perineal lacerations during childbirth

Background

Severe perineal lacerations represent a significant complication of normal labor with a strong impact on quality of life.

Objectives

To identify factors that lead to the occurrence of severe perineal lacerations.

Search strategy

We searched MEDLINE, Scopus, ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials, Google Scholar and reference lists from all included studies.

Selection criteria

We included prospective and retrospective observational studies.

Data collection and analysis

Predetermined data were collected and analyzed with the Mantel–Haenszel fixed-effects model or the DerSimonian–Laird random-effects model.

Main results

The meta-analysis included 22 studies (n = 651 934). Women with severe perineal tears were more likely to have had heavier infants (mean difference 192.88 g [95% CI, 139.80–245.96 g]), an episiotomy (OR 3.82 [95% CI, 1.96–7.42]), or an operative vaginal delivery (OR 5.10 [95% CI, 3.33–7.83]). Epidural anesthesia (OR 1.95 [95% CI, 1.63–2.32]), labor induction (OR 1.08 [95% CI, 1.02–1.14]), and labor augmentation (OR 1.95 [95% CI, 1.56–2.44]) were also more common among women with perineal lacerations.

Conclusions

Various factors contribute to the occurrence of perineal lacerations. Future studies should consistently evaluate all examined parameters to determine their possible interrelation.     

Near-miss o casi pérdida en un hospital de referencia

Objectives

To analyze maternal health from direct mortality and the concept of near-miss at La Fe University Hospital in Valencia (Spain) from 1991 to 2007.

Material and methods

We calculated the direct maternal mortality ratio (DMMR) from 1971-2007 and the severe obstetric morbility-mortality ratio from 1991-2007, and analyzed their causes.

Results

A significant DMMR decrease (rho = - 1), with a significant reduction in mortality due to cardiovascular disease was found. When analyzing severe maternal morbidity, we observed an increase of placenta previa (OR = 1.79), abruptio placentae (OR = 1.35), uterine rupture (OR = 2.48) and anesthetic complications (OR = 6.20), with a significant decrease of postpartum hemorrhage (OR = 0.63) and severe puerperal infection (OR = 0.32).The prevalence of hypertensive disorders of pregnancy, thromboembolic disease, intrauterine fetal death and severe morbidity/mortality ratio remained stable during the study period.

Conclusions

Estimating the severe obstetric morbidity-mortality ratio due to different near-miss definitions in the literature is difficult. The DMMR decreased, while the morbidity/mortality ratio remained stable.     

Prevalence and risk factors of bacterial vaginosis during the first trimester of pregnancy in a large French population-based study

Objectives

Bacterial vaginosis is a risk factor for preterm delivery. Its prevalence and risk factors in Europe are not well known. Our objective was to assess both in early pregnancy.

Study design

As part of the PREMEVA randomized controlled trial, this population-based study included 14,193 women screened before 14 weeks’ gestation for bacterial vaginosis in the 160 laboratories of the Nord-Pas-de-Calais region in France. Bacterial vaginosis was defined by a Nugent score ≥ 7. Data were collected about maternal tobacco use, age, education, and history of preterm birth. We estimated the prevalence of bacterial vaginosis and used a multilevel logistic regression model to identify significant risk factors for it.

Results

Among the 14,193 women assessed before 14 weeks’ gestation, the prevalence of bacterial vaginosis was 7.1% (95% CI: 6.6–7.5%). In the multivariate analysis, smoking during pregnancy tobacco (adjusted OR: 1.38; 95% CI: 1.19–1.60), maternal age 18–19 years (adjusted OR: 1.40; 95% CI: 1.01–1.93), and educational level (completed only primary school: adjusted OR: 1.77; 95% CI: 1.35–2.31; completed only secondary school: adjusted OR: 1.27; 95% CI: 1.10–1.48) were independent risk factors for bacterial vaginosis. History of preterm delivery was not an independent risk factor of bacterial vaginosis: adjusted OR: 1.15; 95% CI: 0.90–1.47.

Conclusion

In a large sample of women in their first trimester of pregnancy in France, the prevalence of bacterial vaginosis was lower than rates reported in other countries, but risk factors were similar: young age, low level of education, and tobacco use during pregnancy. These results should be considered in future strategies to reduce preterm delivery.     

Maternal hyperglycemia and adverse pregnancy outcomes in Dar es Salaam,Tanzania

Objective

To evaluate maternal glucose levels during pregnancy as a predictor of adverse perinatal outcomes in Dar es Salaam, Tanzania.

Methods

Random blood glucose measurements were analyzed from 3383 pregnant women enrolled in a randomized trial to assess the impact of multivitamins on pregnancy outcomes in Dar es Salaam between August 2001 and July 2004. Information on maternal and neonatal morbidity was recorded at monthly study visits, delivery, and 6 weeks postpartum. Binomial regression and generalized estimating equations were used to determine the relationship between elevated glucose (> 7.8 mmol/L) and pregnancy outcomes.

Results

In total, 25 women had elevated glucose (0.7%). Hyperglycemia was associated with an increased risk of delivery before 37 weeks [relative risk (RR), 2.11; 95% confidence interval [CI], 1.07–4.13; P = 0.03), delivery before 34 weeks (RR, 4.15; 95% CI, 1.43–12.03, P = 0.009), incident gestational hypertension (RR, 2.90; 95% CI, 1.24–6.76; P = 0.01), low birth weight (RR, 2.87; 95% CI, 1.18–6.99; P = 0.02), reduced newborn head circumference (mean difference, –1.57; 95% CI, –2.51 to − 0.62; P = 0.001), and fetal loss (RR, 3.38; 95% CI, 1.13–10.08; P = 0.03).

Conclusion

Maternal hyperglycemia is uncommon among pregnant Tanzanian women, but nonetheless seems to increase the risk of several adverse perinatal outcomes.     

Obstetric and neonatal outcomes of twin pregnancies conceived by assisted reproductive technology compared with twin pregnancies conceived spontaneously: a prospective follow-up study

Objective

To compare the obstetric and neonatal outcomes of twin pregnancies conceived by assisted reproduction technology (ART) with spontaneously conceived (SC) twin pregnancies.

Study design

A prospective cohort study compared all dichorionic twin pregnancies in nulliparous women following fresh in vitro fertilization/intra-cytoplasmic sperm injection (ICSI) or ICSI cycles at Royan Institute (n = 320) with SC dichorionic twin pregnancies in nulliparous women at Arash Women's hospital (n = 170) from January 2008 to October 2010. These pregnancies were followed-up until hospital discharge following delivery. Obstetric and neonatal outcomes of SC and ART twin pregnancies were compared.

Results

Multivariate analysis, adjusted for maternal age and body mass index, revealed that the obstetric outcomes were similar in both groups. However, the risks of very preterm birth [odds ratio (OR) 5.2, 95% confidence interval (CI) 2.1–12.9], extremely low birth weight (OR 2.2, 95% CI 1.0–3.9), admission to a neonatal intensive care unit (OR 2.0, 95% CI 1.2–3.2) and perinatal mortality (OR 2.3, 95% CI 1.2–4.0) were higher in the ART group.

Conclusions

The maternal outcomes of ART dichorionic twins were comparable with those of SC twins. However, despite the same obstetric management, the rates of very preterm birth, extremely low birth weight, admission to a neonatal intensive care unit and perinatal mortality were significantly higher in the ART group.     

Predictors of unknown HIV serostatus at the time of labor and delivery in Kampala,Uganda

Objective

To determine factors associated with an unknown HIV serostatus among pregnant women admitted in labor to Mulago Hospital, Kampala, Uganda.

Methods

In total, 665 pregnant women admitted to Mulago Hospital were interviewed about their sociodemographic characteristics, obstetric history, access to prenatal care, fears regarding HIV testing, and knowledge about modes of mother-to-child-transmission (MTCT). Knowledge of the HIV serostatus was assessed by self-report and verified by prenatal card review.

Results

The prevalence of unknown HIV serostatus at the time of labor was 27.1%. Factors associated with an unknown HIV serostatus included high parity (odds ratio [OR] 1.9; 95% confidence interval [CI], 1.16–3.14), preterm delivery (OR 2.60; 95% CI, 1.06–6.34), prenatal care at a private clinic (OR 12.87; 95% CI, 5.68–29.14), residence more than 5 km from the nearest prenatal clinic (OR 2.86; 95% CI, 1.18–17.9), high knowledge about MTCT (OR 0.25; 95% CI, 0.07–0.86), and fears related to disclosing the test result to the partner (OR 3.60; 95% CI, 1.84–7.06).

Conclusion

The high prevalence of unknown HIV serostatus among women in labor highlights the need to improve accessibility to HIV testing services early during pregnancy to be able to take advantage of antiretroviral therapy.     

Carcinosarcoma of the ovary: Natural history,patterns of treatment,and outcome

Objective

Ovarian carcinosarcomas (OCS) are rare tumors composed of both malignant epithelial and mesenchymal elements. We compared the natural history and outcomes of OCS to serous carcinoma of the ovary.

Methods

Patients with OCS and serous carcinomas registered in the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2007 were analyzed. Demographic and clinical characteristics were compared using chi square tests while survival was analyzed using Cox proportional hazards models and the Kaplan–Meier method.

Results

A total of 27,737 women, including 1763 (6.4%) with OCS and 25,974 (93.6%) with serous carcinomas, were identified. Patients with carcinosarcomas tended to be older and have unstaged tumors (P < 0.0001). After adjusting for other prognostic factors, women with carcinosarcomas were 72% more likely to die from their tumors (HR = 1.72; 95% CI, 1.52–1.96). Five-year survival for stage I carcinosarcomas was 65.2% (95% CI, 58.0–71.4%) vs. 80.6% (95% CI, 78.9–82.2%) for serous tumors. Similarly, five-year survival for stage IIIC patients was 18.2% (95% CI, 14.5–22.4%) for carcinosarcomas compared to 33.3% (95% 32.1–34.5%) for serous carcinomas.

Conclusions

Ovarian carcinosarcomas are aggressive tumors with a natural history that is distinct from serous cancers. The survival for both early and late stage carcinosarcoma is inferior to serous tumors.     

Exploring the sustainability of obstetric near-miss case reviews: a qualitative study in the South of Benin

Introduction

near-miss case reviews are one of a number of audit approaches currently being used and evaluated by those with an interest in reducing high rates of maternal mortality in developing countries. Researchers are beginning to take an interest in issues relating to the sustainability of audits.

Objective

to develop an understanding of the barriers and facilitators to the sustainability of obstetric near-miss case reviews in five hospitals in southern Benin.

Design and methods

semi-structured interviews were designed to explore health workers’ and policy makers’ views and experiences of the sustainability of near-miss case reviews aimed to improve quality of care and reduce maternal mortality.

Setting

five hospitals in three regions in the south of Benin.

Participants

two Ministry of Health officials and eight health-care workers involved in a feasibility study conducted in 1998–2001 that introduced near-miss case reviews.

Analysis

framework analysis to identify themes.

Findings

while all participants believed in the importance and value of audit, all hospitals had stopped performing near-miss case reviews within two years of completing the feasibility study. Ten qualitative interviews identified six themes relating to the sustainability of case reviews: clear advantages in ensuring quality of care, fear of blame and punishment, availability of resources, training, supportive hospital work environment, and broader policy issues.

Key conclusions and implications for practice

implementing and sustaining audit is a complex intervention that requires careful planning and consideration. It is important to consider both the content and the context in which audit takes place when developing strategies for sustainability.