The impact of a universal late third-trimester scan for fetal growth restriction on perinatal outcomes in term singleton births: a prospective cohort study

Objective:&nbsp;To investigate perinatal mortality, morbidity and obstetric intervention following the introduction of a universal late third-trimester ultrasound scan for growth restriction. Design:&nbsp;Prospective cohort study Setting:&nbsp;Oxfordshire (OUH), UK Population:&nbsp;Women with a non-anomalous singleton pregnancy undergoing pregnancy care and term delivery at OUH with an estimated date of birth between 01/Jan/2014 and 30/Sept/2019. Methods:&nbsp;Universal ultrasound for fetal growth restriction between 35+0&nbsp;and 36+6&nbsp;weeks was introduced in 2016. The outcomes of the next 18631 eligible term pregnancies were compared, adjusting for covariates and time, with the previous 18636 who had clinically-indicated ultrasounds only. &lsquo;Screen positives&rsquo; for growth restriction were managed according to a pre-determined protocol which included non-intervention for some SGA babies. Main Outcome Measures:&nbsp;Extended perinatal mortality, a composite of mortality or encephalopathy Grade II-III, and expedited birth. Other outcomes included composite adverse outcomes used elsewhere, detection of low birthweight and birth from 37+0&nbsp;to 38+6&nbsp;weeks. Results:&nbsp;Extended perinatal deaths decreased 27% and severe morbidity decreased 33% but neither change was statistically significant (aOR 0.53; 00.18-1.56 and aOR 0.71; 0.31-1.63). Expedited births changed from 35.2% to 37.7% (aOR: 0.99 (0.92 &ndash; 1.06). Birthweight (&lt;10th&nbsp;centile) detection using fetal biometry alone was 31.4% and rose to 40.5% if all abnormal scan parameters were used. Conclusion:&nbsp;Improvements in mortality and severe morbidity subsequent to introducing a universal ultrasound for growth restriction are encouraging but remain unclear. Little change in intervention is possible. The antenatal detection of low birthweight remains poor but improves where markers of growth restriction are used.</p

Late pregnancy ultrasound parameters identifying fetuses at risk of adverse perinatal outcomes: a protocol for a systematic review of systematic reviews

Introduction Stillbirths and neonatal deaths are leading contributors to the global burden of disease and pregnancy ultrasound has the potential to help decrease this burden. In the absence of high-Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence on universal obstetric ultrasound screening at or close to term, many different screening strategies have been proposed. Systematic reviews have rapidly increased over the past decade owing to the diverse nature of ultrasound parameters and the wide range of possible adverse perinatal outcomes. This systematic review will summarise the evidence on key ultrasound parameters in the published literature to help develop an obstetric ultrasound protocol that identifies pregnancies at risk of adverse perinatal outcomes at or close to term. Methods This study will follow the recent Cochrane guidelines for a systematic review of systematic reviews. A comprehensive literature search will be conducted using Embase (OvidSP), Medline (OvidSP), CDSR, CINAHL (EBSCOhost) and Scopus. Systematic reviews evaluating at least one ultrasound parameter in late pregnancy to detect pregnancies at risk of adverse perinatal outcomes will be included. Two independent reviewers will screen, assess the quality including the risk of bias using the ROBIS tool, and extract data from eligible systematic reviews that meet the study inclusion criteria. Overlapping data will be assessed and managed with decision rules, and study evidence including the GRADE assessment of the certainty of results will be presented as a narrative synthesis as described in the Cochrane guidelines for an overview of reviews. Ethics and dissemination This research uses publicly available published data; thus, an ethics committee review is not required. The findings will be published in a peer-reviewed journal. PROSPERO registration number CRD42021266108

Women's experiences of mistreatment during childbirth and their satisfaction with care: findings from a multicountry community-based study in four countries

INTRODUCTION: Experiences of care and satisfaction are intrinsically linked, as user's experiences of care may directly impact satisfaction, or indirectly impact user's expectations and values. Both experiences of care and satisfaction are important to measure so that quality can be monitored and improved. Globally, women experience mistreatment during childbirth at facilities; however, there is limited evidence exploring the mistreatment and women's satisfaction with care during childbirth. METHODS: This is a secondary analysis of a cross-sectional survey within the WHO study 'How women are treated during facility-based childbirth' exploring the mistreatment of women during childbirth in Ghana, Guinea, Myanmar and Nigeria. Women's experiences of mistreatment and satisfaction with care during childbirth was explored. Multivariable logistic regression modelling was conducted to evaluate the association between mistreatment, women's overall satisfaction with the care they received, and whether they would recommend the facility to others. RESULTS: 2672 women were included in this analysis. Despite over one-third of women reporting experience of mistreatment (35.4%), overall satisfaction for services received and recommendation of the facility to others was high, 88.4% and 90%, respectively. Women who reported experiences of mistreatment were more likely to report lower satisfaction with care: women were more likely to be satisfied if they did not experience verbal abuse (adjusted OR (AOR) 4.52, 95% CI 3.50 to 5.85), or had short waiting times (AOR 5.12, 95% CI 3.94 to 6.65). Women who did not experience any physical or verbal abuse or discrimination were more likely to recommend the facility to others (AOR 3.89, 95% CI 2.98 to 5.06). CONCLUSION: Measuring both women's experiences and their satisfaction with care are critical to assess quality and provide actionable evidence for quality improvement. These measures can enable health systems to identify and respond to root causes contributing to measures of satisfaction

Labour companionship and women's experiences of mistreatment during childbirth: results from a multi-country community-based survey

BACKGROUND: Evidence has shown the benefits of labour companions during childbirth. Few studies have documented the relationship between the absence of labour companions and mistreatment of women during childbirth in low-income and middle-income countries using a standardised tool. METHODS: We conducted a secondary analysis of the WHO multi-country study on how women are treated during childbirth, where a cross-sectional community survey was conducted with women up to 8 weeks after childbirth in Ghana, Guinea, Nigeria and Myanmar. Descriptive analysis and multivariable logistic regression were used to examine whether labour companionship was associated with various types of mistreatment. RESULTS: Of 2672 women, about half (50.4%) reported the presence of a labour companion. Approximately half (49.6%) of these women reported that the timing of support was during labour and after childbirth and most of the labour companions (47.0%) were their family members. Across Ghana, Guinea and Nigeria, women without a labour companion were more likely to report physical abuse, non-consented medical procedures and poor communication compared with women with a labour companion. However, there were country-level variations. In Guinea, the absence of labour companionship was associated with any physical abuse, verbal abuse, or stigma or discrimination (adjusted OR (AOR) 3.6, 1.9-6.9) and non-consented vaginal examinations (AOR 3.2, 1.6-6.4). In Ghana, it was associated with non-consented vaginal examinations (AOR 2.3, 1.7-3.1) and poor communication (AOR 2.0, 1.3-3.2). In Nigeria, it was associated with longer wait times (AOR 0.6, 0.3-0.9). CONCLUSION: Labour companionship is associated with lower levels of some forms of mistreatment that women experience during childbirth, depending on the setting. Further work is needed to ascertain how best to implement context-specific labour companionship to ensure benefits while maintaining women's choices and autonomy

The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicountry, facility-based, observational study

BACKGROUND: Amid efforts to improve the quality of care for women and neonates during childbirth, there is growing interest in the experience of care, including respectful care practices. However, there is little research on the prevalence of practices that might constitute mistreatment of neonates. This study aims to describe the care received by neonates up to 2 h after birth in a sample of three countries in west Africa. METHODS: Data from this multicountry, facility-based, observational study were collected on 15 neonatal care practices across nine facilities in Ghana, Guinea, and Nigeria, as part of WHO's wider multicountry study on how women are treated during childbirth. Women were eligible if they were admitted to the participating health facilities for childbirth, in early established labour or active labour, aged 15 years or older, and provided written informed consent on behalf of themselves and their neonate. All labour observations were continuous, one-to-one observations of women and neonates by independent data collectors. Descriptive statistics and multivariate logistic regressions were used to examine associations between these neonatal care practices, maternal and neonate characteristics, and maternal mistreatment. Early neonate deaths, stillbirths, and higher order multiple births were excluded from analysis. FINDINGS: Data collection took place from Sept 19, 2016, to Feb 26, 2017, in Nigeria; from Aug 1, 2017, to Jan 18, 2018, in Ghana; and from July 1 to Oct 30, 2017, in Guinea. We included data for 362 women-neonate dyads (356 [98%] with available data for neonatal care practices) in Nigeria, 760 (749 [99%]) in Ghana, and 558 (522 [94%]) in Guinea. Delayed cord clamping was done for most neonates (1493 [91·8%] of 1627); other practices, such as skin-to-skin contact, were less commonly done (1048 [64·4%]). During the first 2 h after birth, separation of the mother and neonate occurred in 844 (51·9%) of 1627 cases; and was more common for mothers who were single (adjusted odds ratio [AOR; adjusting for country, maternal age, education, marital status, neonate weight at birth, and neonate sex] 1·8, 95% CI 1·3-2·6) than those who were married or cohabiting. Lack of maternal education was associated with increased likelihood of neonates not receiving recommended breastfeeding practices. Neonates with a low birthweight (<2·5 kg) were more likely (1·7, 1·1-2·8) to not begin breastfeeding on demand than full weight neonates. When women experienced physical abuse from providers within 1 h before childbirth, their neonates were more likely to be slapped (AOR 1·9, 1·1-3·9). INTERPRETATION: A high proportion of neonates did not receive recommended care practices, and some received practices that might constitute mistreatment. Further research is needed on understanding and measuring mistreatment to improve care, including respectful care, for mothers and neonates. FUNDING: US Agency for International Development, and the UNDP/UN Population Fund/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO

How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys

BACKGROUND: Women across the world are mistreated during childbirth. We aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries. METHODS: We prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment. FINDINGS: 2016 labour observations and 2672 surveys were done. 838 (41·6%) of 2016 observed women and 945 (35·4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 [75·1%] of 253; survey: 295 [56·1%] of 526) or caesarean section (observation: 35 [13·4%] of 261; survey: 52 [10·8%] of 483), despite receiving these procedures. 133 (5·0%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15-19 years) and lack of education were the primary determinants of mistreatment (survey). For example, younger women with no education (odds ratio [OR] 3·6, 95% CI 1·6-8·0) and younger women with some education (OR 1·6, 1·1-2·3) were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status and parity. INTERPRETATION: More than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context. FUNDING: United States Agency for International Development and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO