Summary Background Data for the causes of maternal deaths are needed to inform policies to improve maternal health. We developed and analysed global, regional, and subregional estimates of the causes ...of maternal death during 2003–09, with a novel method, updating the previous WHO systematic review. Methods We searched specialised and general bibliographic databases for articles published between between Jan 1, 2003, and Dec 31, 2012, for research data, with no language restrictions, and the WHO mortality database for vital registration data. On the basis of prespecified inclusion criteria, we analysed causes of maternal death from datasets. We aggregated country level estimates to report estimates of causes of death by Millennium Development Goal regions and worldwide, for main and subcauses of death categories with a Bayesian hierarchical model. Findings We identified 23 eligible studies (published 2003–12). We included 417 datasets from 115 countries comprising 60 799 deaths in the analysis. About 73% (1 771 000 of 2 443 000) of all maternal deaths between 2003 and 2009 were due to direct obstetric causes and deaths due to indirect causes accounted for 27·5% (672 000, 95% UI 19·7–37·5) of all deaths. Haemorrhage accounted for 27·1% (661 000, 19·9–36·2), hypertensive disorders 14·0% (343 000, 11·1–17·4), and sepsis 10·7% (261 000, 5·9–18·6) of maternal deaths. The rest of deaths were due to abortion (7·9% 193 000, 4·7–13·2), embolism (3·2% 78 000, 1·8–5·5), and all other direct causes of death (9·6% 235 000, 6·5–14·3). Regional estimates varied substantially. Interpretation Between 2003 and 2009, haemorrhage, hypertensive disorders, and sepsis were responsible for more than half of maternal deaths worldwide. More than a quarter of deaths were attributable to indirect causes. These analyses should inform the prioritisation of health policies, programmes, and funding to reduce maternal deaths at regional and global levels. Further efforts are needed to improve the availability and quality of data related to maternal mortality. Funding USAID, the US Fund for UNICEF through a grant from the Bill & Melinda Gates Foundation to CHERG, and The UNDP/UNFPA/UNICEF/WHO/The World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research.
Summary Background Stillbirths do not count in routine worldwide data-collating systems or for the Millennium Development Goals. Two sets of national stillbirth estimates for 2000 produced similar ...worldwide totals of 3·2 million and 3·3 million, but rates differed substantially for some countries. We aimed to develop more reliable estimates and a time series from 1995 for 193 countries, by increasing input data, using recent data, and applying improved modelling approaches. Methods For international comparison, stillbirth is defined as fetal death in the third trimester (≥1000 g birthweight or ≥28 completed weeks of gestation). Several sources of stillbirth data were identified and assessed against prespecified inclusion criteria: vital registration data; nationally representative surveys; and published studies identified through systematic literature searches, unpublished studies, and national data identified through a WHO country consultation process. For 2009, reported rates were used for 33 countries and model-based estimates for 160 countries. A regression model of log stillbirth rate was developed and used to predict national stillbirth rates from 1995 to 2009. Uncertainty ranges were obtained with a bootstrap approach. The final model included log(neonatal mortality rate) (cubic spline), log(low birthweight rate) (cubic spline), log(gross national income purchasing power parity) (cubic spline), region, type of data source, and definition of stillbirth. Findings Vital registration data from 79 countries, 69 nationally representative surveys from 39 countries, and 113 studies from 42 countries met inclusion criteria. The estimated number of global stillbirths was 2·64 million (uncertainty range 2·14 million to 3·82 million) in 2009 compared with 3·03 million (uncertainty range 2·37 million to 4·19 million) in 1995. Worldwide stillbirth rate has declined by 14·5%, from 22·1 stillbirths per 1000 births in 1995 to 18·9 stillbirths per 1000 births in 2009. In 2009, 76·2% of stillbirths occurred in south Asia and sub-Saharan Africa. Interpretation This study draws attention to the dearth of reliable data in regions where most stillbirths occur. The estimated trend in stillbirth rate reduction is slower than that for maternal mortality and lags behind the increasing progress in reducing deaths in children younger than 5 years. Improved data and improved use of data are crucial to ensure that stillbirths count in global and national policy. Funding The Bill & Melinda Gates Foundation through the Global Alliance to Prevent Prematurity and Stillbirth, Saving Newborn Lives/Save the Children, and the International Stillbirth Alliance. The Department of Reproductive Health and Research, WHO, through the UN Development Programme, UN Population Fund, WHO, and World Bank Special Programme of Research, Development and Research Training in Human Reproduction.
Background
Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research ...can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes.
This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future.
Objectives
To identify, appraise, and synthesise qualitative studies exploring:
· Women’s views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women’s accounts;
· Healthcare providers’ views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers.
Search methods
To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase.
Selection criteria
We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided.
We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education.
Data collection and analysis
Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta‐ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE‐CERQual. We used these findings to generate higher‐level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane effectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour.
Main results
We include 85 studies in our synthesis. Forty‐six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high‐income countries, 18 middle‐income countries and 15 low‐income countries, in rural, urban and semi‐urban locations. We developed 52 findings in total and organised these into three thematic domains: socio‐cultural context (11 findings, five moderate‐ or high‐confidence); service design and provision (24 findings, 15 moderate‐ or high‐confidence); and what matters to women and staff (17 findings, 11 moderate‐ or high‐confidence) The third domain was sub‐divided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using high‐ or moderate‐confidence findings:
For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good‐quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women’s need for privacy, and that allow staff to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women’s perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio‐cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time.
The capacity of healthcare providers to deliver the kind of high‐quality, relationship‐based, locally accessible ANC that is likely to facilitate access by women depends on the provision of sufficient resources and staffing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring staff who make effective, culturally‐appropriate links with local communities, who respect women’s belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require sufficient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies.
Authors' conclusions
This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good‐quality ANC by healthcare providers. It complements existing effectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.
Scoping reviews, a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps. Although more scoping ...reviews are being done, their methodological and reporting quality need improvement. This document presents the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist and explanation. The checklist was developed by a 24-member expert panel and 2 research leads following published guidance from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network. The final checklist contains 20 essential reporting items and 2 optional items. The authors provide a rationale and an example of good reporting for each item. The intent of the PRISMA-ScR is to help readers (including researchers, publishers, commissioners, policymakers, health care providers, guideline developers, and patients or consumers) develop a greater understanding of relevant terminology, core concepts, and key items to report for scoping reviews.
Summary Background Rates of caesarean section surgery are rising worldwide, but the determinants of this increase, especially in low-income and middle-income countries, are controversial. In this ...study, we aimed to analyse the contribution of specific obstetric populations to changes in caesarean section rates, by using the Robson classification in two WHO multicountry surveys of deliveries in health-care facilities. The Robson system classifies all deliveries into one of ten groups on the basis of five parameters: obstetric history, onset of labour, fetal lie, number of neonates, and gestational age. Methods We studied deliveries in 287 facilities in 21 countries that were included in both the WHO Global Survey of Maternal and Perinatal Health (WHOGS; 2004–08) and the WHO Multi-Country Survey of Maternal and Newborn Health (WHOMCS; 2010–11). We used the data from these surveys to establish the average annual percentage change (AAPC) in caesarean section rates per country. Countries were stratified according to Human Development Index (HDI) group (very high/high, medium, or low) and the Robson criteria were applied to both datasets. We report the relative size of each Robson group, the caesarean section rate in each Robson group, and the absolute and relative contributions made by each to the overall caesarean section rate. Findings The caesarean section rate increased overall between the two surveys (from 26·4% in the WHOGS to 31·2% in the WHOMCS, p=0·003) and in all countries except Japan. Use of obstetric interventions (induction, prelabour caesarean section, and overall caesarean section) increased over time. Caesarean section rates increased across most Robson groups in all HDI categories. Use of induction and prelabour caesarean section increased in very high/high and low HDI countries, and the caesarean section rate after induction in multiparous women increased significantly across all HDI groups. The proportion of women who had previously had a caesarean section increased in moderate and low HDI countries, as did the caesarean section rate in these women. Interpretation Use of the Robson criteria allows standardised comparisons of data across countries and timepoints and identifies the subpopulations driving changes in caesarean section rates. Women who have previously had a caesarean section are an increasingly important determinant of overall caesarean section rates in countries with a moderate or low HDI. Strategies to reduce the frequency of the procedure should include avoidance of medically unnecessary primary caesarean section. Improved case selection for induction and prelabour caesarean section could also reduce caesarean section rates. Funding None.
Despite growing recognition of neglectful, abusive, and disrespectful treatment of women during childbirth in health facilities, there is no consensus at a global level on how these occurrences are ...defined and measured. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence on the mistreatment of women during childbirth in health facilities to inform the development of an evidence-based typology of the phenomenon.
We searched PubMed, CINAHL, and Embase databases and grey literature using a predetermined search strategy to identify qualitative, quantitative, and mixed-methods studies on the mistreatment of women during childbirth across all geographical and income-level settings. We used a thematic synthesis approach to synthesize the qualitative evidence and assessed the confidence in the qualitative review findings using the CERQual approach. In total, 65 studies were included from 34 countries. Qualitative findings were organized under seven domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints. Due to high heterogeneity of the quantitative data, we were unable to conduct a meta-analysis; instead, we present descriptions of study characteristics, outcome measures, and results. Additional themes identified in the quantitative studies are integrated into the typology.
This systematic review presents a comprehensive, evidence-based typology of the mistreatment of women during childbirth in health facilities, and demonstrates that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system levels. We propose this typology be adopted to describe the phenomenon and be used to develop measurement tools and inform future research, programs, and interventions.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Anaemia affects as many as half of all pregnant women in low-income and middle-income countries, but the burden of disease and associated maternal mortality are not robustly quantified. We aimed to ...assess the association between severe anaemia and maternal death with data from the WHO Multicountry Survey on maternal and newborn health.
We used multilevel and propensity score regression analyses to establish the relation between severe anaemia and maternal death in 359 health facilities in 29 countries across Latin America, Africa, the Western Pacific, eastern Mediterranean, and southeast Asia. Severe anaemia was defined as antenatal or postnatal haemoglobin concentrations of less than 70 g/L in a blood sample obtained before death. Maternal death was defined as death any time after admission until the seventh day post partum or discharge. In regression analyses, we adjusted for post-partum haemorrhage, general anaesthesia, admission to intensive care, sepsis, pre-eclampsia or eclampsia, thrombocytopenia, shock, massive transfusion, severe oliguria, failure to form clots, and severe acidosis as confounding variables. These variables were used to develop the propensity score.
312 281 women admitted in labour or with ectopic pregnancies were included in the adjusted multilevel logistic analysis, and 12 470 were included in the propensity score regression analysis. The adjusted odds ratio for maternal death in women with severe anaemia compared with those without severe anaemia was 2·36 (95% CI 1·60–3·48). In the propensity score analysis, severe anaemia was also associated with maternal death (adjusted odds ratio 1·86 95% CI 1·39–2·49).
Prevention and treatment of anaemia during pregnancy and post partum should remain a global public health and research priority.
Barts and the London Charity.
Escalation in the global rates of labour interventions, particularly cesarean section and oxytocin augmentation, has renewed interest in a better understanding of natural labour progression. ...Methodological advancements in statistical and computational techniques addressing the limitations of pioneer studies have led to novel findings and triggered a re-evaluation of current labour practices. As part of the World Health Organization's Better Outcomes in Labour Difficulty (BOLD) project, which aimed to develop a new labour monitoring-to-action tool, we examined the patterns of labour progression as depicted by cervical dilatation over time in a cohort of women in Nigeria and Uganda who gave birth vaginally following a spontaneous labour onset.
This was a prospective, multicentre, cohort study of 5,606 women with singleton, vertex, term gestation who presented at ≤ 6 cm of cervical dilatation following a spontaneous labour onset that resulted in a vaginal birth with no adverse birth outcomes in 13 hospitals across Nigeria and Uganda. We independently applied survival analysis and multistate Markov models to estimate the duration of labour centimetre by centimetre until 10 cm and the cumulative duration of labour from the cervical dilatation at admission through 10 cm. Multistate Markov and nonlinear mixed models were separately used to construct average labour curves. All analyses were conducted according to three parity groups: parity = 0 (n = 2,166), parity = 1 (n = 1,488), and parity = 2+ (n = 1,952). We performed sensitivity analyses to assess the impact of oxytocin augmentation on labour progression by re-examining the progression patterns after excluding women with augmented labours. Labour was augmented with oxytocin in 40% of nulliparous and 28% of multiparous women. The median time to advance by 1 cm exceeded 1 hour until 5 cm was reached in both nulliparous and multiparous women. Based on a 95th percentile threshold, nulliparous women may take up to 7 hours to progress from 4 to 5 cm and over 3 hours to progress from 5 to 6 cm. Median cumulative duration of labour indicates that nulliparous women admitted at 4 cm, 5 cm, and 6 cm reached 10 cm within an expected time frame if the dilatation rate was ≥ 1 cm/hour, but their corresponding 95th percentiles show that labour could last up to 14, 11, and 9 hours, respectively. Substantial differences exist between actual plots of labour progression of individual women and the 'average labour curves' derived from study population-level data. Exclusion of women with augmented labours from the study population resulted in slightly faster labour progression patterns.
Cervical dilatation during labour in the slowest-yet-normal women can progress more slowly than the widely accepted benchmark of 1 cm/hour, irrespective of parity. Interventions to expedite labour to conform to a cervical dilatation threshold of 1 cm/hour may be inappropriate, especially when applied before 5 cm in nulliparous and multiparous women. Averaged labour curves may not truly reflect the variability associated with labour progression, and their use for decision-making in labour management should be de-emphasized.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IntroductionInternationally comparable estimates of unintended pregnancy and abortion incidence can illuminate disparities in sexual and reproductive health and autonomy. Country-specific estimates ...are essential to enable international comparison, and to inform country-level policy and programming.MethodsWe developed a Bayesian model which jointly estimated unintended pregnancy and abortion rates using information on contraceptive needs and use, contraceptive method mix, birth rates, the proportions of births from unintended pregnancies and abortion incidence data. Main outcomes were the estimated rates of unintended pregnancy and abortion for 150 countries and territories, reported for the 5-year period 2015–2019, as annual averages per 1000 women aged 15–49 years.ResultsEstimated unintended pregnancy rates ranged from 11 (80% uncertainty interval: 9 to 13) in Montenegro to 145 (131 to 159) in Uganda per 1000 women aged 15–49 years. Between-country heterogeneity was substantial in all Sustainable Development Goal (SDG) regions, but was greatest in sub-Saharan Africa. Estimated abortion rates ranged from 5 (5 to 6) in Singapore to 80 (55 to 113) in Georgia. Variation between country estimates was similar in all SDG regions except for Europe and Northern America, where estimated abortion rates were generally lower.ConclusionThe estimates reflect variation in the degree to unintended pregnancy and abortion that are experienced in countries throughout the world. This evidence highlights the importance of investing in access to contraception and comprehensive abortion care, including in regions which may have lower rates of unintended pregnancy or abortion, respectively, as countries may differ substantially from regional averages.
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