Duration of third stage labour and postpartum blood loss: a secondary analysis of the WHO CHAMPION trial data

Background: Obstetric haemorrhage continues to be a leading cause of maternal mortality, contributing to more than a quarter of the 2,443,000 maternal deaths reported between 2003 and 2009. During this period, about 70% of the haemorrhagic deaths occurred postpartum. In addition to other identifiable risk factors for greater postpartum blood loss, the duration of the third stage of labour (TSL) seems to be important, as literature shows that a longer TSL can be associated with more blood loss. To better describe the association between the duration of TSL and postpartum blood loss in women receiving active management of third stage of labour (AMTSL), this secondary analysis of the WHO CHAMPION trial data has been conducted. Methods: This was a secondary analysis of the WHO CHAMPION trial conducted in twenty-three sites in ten countries. We studied the association between the TSL duration and blood loss in the sub cohort of women from the CHAMPION trial (all of whom received AMTSL), with TSL upto 60 min and no interventions for postpartum haemorrhage. We used a general linear model to fit blood loss as a function of TSL duration on the log scale, arm and center, using a normal distribution and the log link function. We showed this association separately for oxytocin and for Heat stable (HS) carbetocin. Results: For the 10,040 women analysed, blood loss rose steeply with third stage duration in the first 10 min, but more slowly after 10 min. This trend was observed for both Oxytocin and HS carbetocin and the difference in the trends for both drugs was not statistically significant (p-value = 0.2070). Conclusions: There was a positive association between postpartum blood loss and TSL duration with either uterotonic. Blood loss rose steeply with TSL duration until 10 min, and more slowly after 10 min.Fil: Chikkamath, Sumangala B.. S. Nijalingappa Medical College; IndiaFil: Katageri, Geetanjali M.. S. Nijalingappa Medical College; IndiaFil: Mallapur, Ashalata A.. S. Nijalingappa Medical College; IndiaFil: Vernekar, Sunil S.. Jawaharlal Nehru Medical College Belgaum; IndiaFil: Somannavar, Manjunath S.. Jawaharlal Nehru Medical College Belgaum; IndiaFil: Piaggio, Gilda. No especifíca;Fil: Carroli, Guillermo. Centro Rosarino de Estudios Perinatales; ArgentinaFil: de Carvalho, José Ferreira. No especifíca;Fil: Althabe, Fernando. Organizacion Mundial de la Salud; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Hofmeyr, G. Justus. University of Botswana; Estados Unidos. University of the Witwatersrand; SudáfricaFil: Widmer, Mariana. Organizacion Mundial de la Salud; ArgentinaFil: Gulmezoglu, Ahmet Metin. No especifíca;Fil: Goudar, Shivaprasad S.. Jawaharlal Nehru Medical College Belgaum; Indi

A cluster randomized controlled trial to evaluate the effectiveness of the clinically integrated RHL evidence -based medicine course

<p>Abstract</p> <p>Background and objectives</p> <p>Evidence-based health care requires clinicians to engage with use of evidence in decision-making at the workplace. A learner-centred, problem-based course that integrates e-learning in the clinical setting has been developed for application in obstetrics and gynaecology units. The course content uses the WHO reproductive health library (RHL) as the resource for systematic reviews. This project aims to evaluate a clinically integrated teaching programme for incorporation of evidence provided through the WHO RHL. The hypothesis is that the RHL-EBM (clinically integrated e-learning) course will improve participants' knowledge, skills and attitudes, as well as institutional practice and educational environment, as compared to the use of standard postgraduate educational resources for EBM teaching that are not clinically integrated.</p> <p>Methods</p> <p>The study will be a multicentre, cluster randomized controlled trial, carried out in seven countries (Argentina, Brazil, Democratic Republic of Congo, India, Philippines, South Africa, Thailand), involving 50-60 obstetrics and gynaecology teaching units. The trial will be carried out on postgraduate trainees in the first two years of their training. In the intervention group, trainees will receive the RHL-EBM course. The course consists of five modules, each comprising self-directed e-learning components and clinically related activities, assignments and assessments, coordinated between the facilitator and the postgraduate trainee. The course will take about 12 weeks, with assessments taking place pre-course and 4 weeks post-course. In the control group, trainees will receive electronic, self-directed EBM-teaching materials. All data collection will be online.</p> <p>The primary outcome measures are gain in EBM knowledge, change in attitudes towards EBM and competencies in EBM measured by multiple choice questions (MCQs) and a skills-assessing questionniare administered eletronically. These questions have been developed by using questions from validated questionnaires and adapting them to the current course. Secondary outcome measure will be educational environment towards EBM which will be assessed by a specifically developed questionnaire.</p> <p>Expected outcomes</p> <p>The trial will determine whether the RHL EBM (clinically integrated e-leraning) course will increase knowledge, skills and attitudes towards EBM and improve the educational environment as compared to standard teaching that is not clinically integrated. If effective, the RHL-EBM course can be implemented in teaching institutions worldwide in both, low-and middle income countries as well as industrialized settings. The results will have a broader impact than just EBM training because if the approach is successful then the same educational strategy can be used to target other priority clinical and methodological areas.</p> <p>Trial Registration</p> <p>ACTRN12609000198224</p

Cluster randomized trial of an active, multifaceted information dissemination intervention based on The WHO Reproductive health library to change obstetric practices: methods and design issues [ISRCTN14055385]

BACKGROUND: Effective strategies for implementing best practices in low and middle income countries are needed. RHL is an annually updated electronic publication containing Cochrane systematic reviews, commentaries and practical recommendations on how to implement evidence-based practices. We are conducting a trial to evaluate the improvement in obstetric practices using an active dissemination strategy to promote uptake of recommendations in The WHO Reproductive Health Library (RHL). METHODS: A cluster randomized trial to improve obstetric practices in 40 hospitals in Mexico and Thailand is conducted. The trial uses a stratified random allocation based on country, size and type of hospitals. The core intervention consists of three interactive workshops delivered over a period of six months. The main outcome measures are changes in clinical practices that are recommended in RHL measured approximately a year after the first workshop. RESULTS: The design and implementation of a complex intervention using a cluster randomized trial design are presented. CONCLUSION: Designing the intervention, choosing outcome variables and implementing the protocol in two diverse settings has been a time-consuming and challenging process. We hope that sharing this experience will help others planning similar projects and improve our ability to implement change

WHO Global Survey on Maternal and Perinatal Health in Latin America: classifying caesarean sections

<p>Abstract</p> <p>Background</p> <p>Caesarean section rates continue to increase worldwide with uncertain medical consequences. Auditing and analysing caesarean section rates and other perinatal outcomes in a reliable and continuous manner is critical for understanding reasons caesarean section changes over time.</p> <p>Methods</p> <p>We analyzed data on 97,095 women delivering in 120 facilities in 8 countries, collected as part of the 2004-2005 Global Survey on Maternal and Perinatal Health in Latin America. The objective of this analysis was to test if the "10-group" or "Robson" classification could help identify which groups of women are contributing most to the high caesarean section rates in Latin America, and if it could provide information useful for health care providers in monitoring and planning effective actions to reduce these rates.</p> <p>Results</p> <p>The overall rate of caesarean section was 35.4%. Women with single cephalic pregnancy at term without previous caesarean section who entered into labour spontaneously (groups 1 and 3) represented 60% of the total obstetric population. Although women with a term singleton cephalic pregnancy with a previous caesarean section (group 5) represented only 11.4% of the obstetric population, this group was the largest contributor to the overall caesarean section rate (26.7% of all the caesarean sections). The second and third largest contributors to the overall caesarean section rate were nulliparous women with single cephalic pregnancy at term either in spontaneous labour (group 1) or induced or delivered by caesarean section before labour (group 2), which were responsible for 18.3% and 15.3% of all caesarean deliveries, respectively.</p> <p>Conclusion</p> <p>The 10-group classification could be easily applied to a multicountry dataset without problems of inconsistencies or misclassification. Specific groups of women were clearly identified as the main contributors to the overall caesarean section rate. This classification could help health care providers to plan practical and effective actions targeting specific groups of women to improve maternal and perinatal care.</p

Classifications for Cesarean Section: A Systematic Review

Background: Rising cesarean section (CS) rates are a major public health concern and cause worldwide debates. To propose and implement effective measures to reduce or increase CS rates where necessary requires an appropriate classification. Despite several existing CS classifications, there has not yet been a systematic review of these. This study aimed to 1) identify the main CS classifications used worldwide, 2) analyze advantages and deficiencies of each system.Methods and Findings: Three electronic databases were searched for classifications published 1968-2008. Two reviewers independently assessed classifications using a form created based on items rated as important by international experts. Seven domains (ease, clarity, mutually exclusive categories, totally inclusive classification, prospective identification of categories, reproducibility, implementability) were assessed and graded. Classifications were tested in 12 hypothetical clinical case-scenarios. From a total of 2948 citations, 60 were selected for full-text evaluation and 27 classifications identified. Indications classifications present important limitations and their overall score ranged from 2-9 (maximum grade = 14). Degree of urgency classifications also had several drawbacks (overall scores 6-9). Woman-based classifications performed best (scores 5-14). Other types of classifications require data not routinely collected and may not be relevant in all settings (scores 3-8).Conclusions: This review and critical appraisal of CS classifications is a methodologically sound contribution to establish the basis for the appropriate monitoring and rational use of CS. Results suggest that women-based classifications in general, and Robson's classification, in particular, would be in the best position to fulfill current international and local needs and that efforts to develop an internationally applicable CS classification would be most appropriately placed in building upon this classification. the use of a single CS classification will facilitate auditing, analyzing and comparing CS rates across different settings and help to create and implement effective strategies specifically targeted to optimize CS rates where necessary.Universidade Federal de São Paulo, Dept Obstet, São Paulo, BrazilBrazilian Cochrane Ctr, São Paulo, BrazilWorld Hlth Org, Dept Reprod Hlth & Res, Geneva, SwitzerlandWorld Hlth Org, Dept Knowledge Management & Sharing, Geneva, SwitzerlandUniversidade Federal de São Paulo, Dept Obstet, São Paulo, BrazilWeb of Scienc

Guidance for Evidence-Informed Policies about Health Systems: Assessing How Much Confidence to Place in the Research Evidence

In the third paper in a three-part series on health systems guidance, Simon Lewin and colleagues explore the challenge of assessing how much confidence to place in evidence on health systems interventions

Using Qualitative Evidence in Decision Making for Health and Social Interventions: An Approach to Assess Confidence in Findings from Qualitative Evidence Syntheses (GRADE-CERQual)

Published onlineJournal ArticleResearch Support, Non-U.S. Gov'tThis is the final version of the article. Available from Public Library of Science via the DOI in this record.Simon Lewin and colleagues present a methodology for increasing transparency and confidence in qualitative research synthesis.This work was supported by funding from the Department of Reproductive Health and Research, WHO (www.who.int/reproductivehealth/about_us/en/) and Norad (Norwegian Agency for Development Cooperation: www.norad.no) to the Norwegian Knowledge Centre for the Health Services. Additional funding for several of the pilot reviews was provided by the Alliance for Health Policy and Systems Research (www.who.int/alliance-hpsr/en/). We also received funding for elements of this work through the Cochrane supported "Methodological Investigation of Cochrane reviews of Complex Interventions" (MICCI) project (www.cochrane.org). SL is supported by funding from the South African Medical Research Council (www.mrc.ac.za). The funders had no role in study design, data collection and analysis, preparation of the manuscript or the decision to publish