Emergency Obstetric Care: Strategy for Reducing Maternal Mortality in Developing Countries

Twenty-five years have passed since the global community agreed in Nairobi to address the high maternal mortality by implementing the Safe Motherhood Initiative. However, every year nearly three million women die due to pregnancy related causes. This tragedy is avoidable if women have timely access to required emergency obstetric care. Emergency obstetric care refers to life-saving services for maternal and neonatal complications provided by skilled health workers. Since the beginning of the 1980’s, several efforts have been intensified to improve maternal and child health status and reducing the high morbidity and mortality. There was built on a worldwide consensus to provide improved maternal and child health care for addressing the high morbidity and mortality. All participant countries agreed to integrate emergency obstetric care services in their national health care system. Emergency obstetric care is one of the strategies for reducing the maternal mortality as pregnancy related complications are unpredictable. However, many women in developing countries do not have access to essential health care services including emergency obstetric care. Basic emergency obstetric care by skilled birth attendants or timely referral for further comprehensive emergency obstetric care can reduce maternal deaths and disabilities significantly. This paper is based on the results published in PubMed, Medline, Lancet, WHO and Google Scholar web pages from 1990 to 2013.http://www.nepjol.info/index.php/NJOG/article/view/1117

Caesarean Section rates in South Asian cities: Can midwifery help stem the rise?

Introduction: Caesarean section (CS) is a life-saving surgical intervention for delivering a baby when complications arisein childbirth. World Health Organization recommends a rate of CS from 10% to 15%. However, CS rates increased steadily in recent decades and have almost doubled from 12.1% in 2000 to 21.1% in 2015. Therefore, this has become a global public health problem. The main purpose of the scoping review article is to give an overview and analysis of the rising CS use in four South Asian countries: Bangladesh, India, Nepal and Pakistan. Methods: A scoping review was carried-out using several bibliographic electronic databases (MEDLINE, EMBASE, SCOPUS, CINAHL and Web of Science), organizational websites and open access journal databases. Literature was searched from December 2011 to December 2018 for articles reporting hospital-based CS rates.Inclusion criteria were primary studies conducted ininstitutional setting in Bangladesh, India, Nepal and Pakistan and published in the English language. Results: We have included 43 studies. Together these studies show that the rate of CS is increasing in all four countries: Nepal, Bangladesh, Pakistan and India. However, this isuneven with very low rates in rural and very high rates in urban settings, theco-existence of ‘Too Little Too Late & Too Much Too Soon’. Hospital based studies have shown that the CS rate is higher in urban and private hospitals. Age, education andsocio-economic status of women, urban residence and distance from health facility are associated with CSs. CS is higher among highlyeducated affluent urban women in private hospitals in South Asian Countries. Conclusion: Rising CS rates in South Asian cities, particularly in specific groups of women, present a challenge to hospital staff and managers and policy-makers. The challenge is to avoid ‘Too Much Too Soon’ in otherwise healthy urban women and avoid ‘Too Little Too Late’ in women living in remote and rural area and in poor urban women

A brief history and indications for cesarean section

Cesarean section (CS) is one of the oldest surgical operations. Originally,this surgery was performed post-mortem by cutting open the woman’s abdomen to remove a dead or alive fetus. It was therefore not intended for saving the mother in ancient times. Roman law and religious rituals shaped the procedure until the Middle Ages. At that time, the indication of CS was only post-mortem. Although CS became a medical procedure in the Renaissance, maternal mortality was extremely high, mainly due to hemorrhage and puerperal infection. The reason for performing CS was to rescue the mother and fetus from protracted labor as a last resort. Since the late 19th century, with the introduction of chloroform and the developments of surgical techniques, and the availability of blood transfusion in the early twentieth century, CS became a relatively safe procedure, further helped by the introduction of antibiotics after World War II. Then, CS was increasingly an intervention to preserve the health and safety of both mother and fetus. During the 21st century, CS has been performed even without medical indication, such as maternal choice. Advancement of obstetric practice technologically and professionally during the period as well as changing attitudes of both obstetricians and childbearing women meant indications for CS are no longer limited to medical/obstetric indications. CS is perceived as a safer mode of childbirth. Therefore, the indications of CS have been changed drastically from ancient times (rescuing a baby from dying or dead mother) to the 21st century (maternal choice/reproductive rights)

Classification of Caesarean Section: A Scoping Review of the Robson classification

Caesarean section (CS) rate is rising dramatically worldwide. WHO recommended CS rate of 10-15% at population level would not be the ideal rate at the hospitals level due to the differences on population they have been serving. At the hospital level, a perfectly effective system is necessary to understand the trends and causes of rising trends of CS as well as to implement effective measures where necessary to control the same. Hence, WHO recommended the Robson classification, which is also called the 10-group classification of CS (TGCS) as a global standard tool to assess, monitor and compare CS rates within healthcare facilities over time, and between health facilities. The Robson classification, proposed by Dr Michael Robson in 2001, is a system that classifies all women at admission at a specific health facility for childbirth into 10 groups based on five basic obstetric characteristics (parity, gestational age, onset of labour, foetal presentation and number of foetuses). This classification is easy and simple and mutually exclusive, highly reproducible, easily applicable, and useful to change clinical practice. It has many strengths such as simplicity, flexibility (further subdivisions can be made to increase homogeneity within groups). This classification helps to identify and analyse the contribution of each group to overall CS rates. It also allows distinguishing the main group of women who contributes most and least to the overall CS rates; so that the CS rates can be monitored in a meaningful, reliable, and action-oriented manner in each health facility for optimal use of C

Rising Rate of Caesarean Section in Urban Nepal

The rising rate of caesarean section in urban Nepal is alarming as the lack of access for women in rural areas to emergency obstetric care, putting lives at risk. The latter is referred to as ‘Too little too late’. At the same time, the sharp rise in caesarean section rates in cities presents the other extreme: “Too much too soon”. The overuse of caesarean section causes harm, unnecessary costs, and misuse of health resources. Availability of private hospitals and increasing hospital childbirth may contribute to the rising rate of caesarean section. This article highlights the rising rate of caesarean section in urban Nepal

Factors contributing to rising cesarean section rates in South Asian countries: A systematic review

Rising cesarean section (CS) rates are a global public health problem. The systematic review investigates key indications for performing CS and factors significantly associated with the rising rate of CS in South Asia. Primary studies in South Asia published between January 2010 and December 2018 were searched using relevant electronic databases: MEDLINE, Scopus, PubMed, Web of Science, CINAHL, NepJOL, and BanglaJOL. A narrative synthesis of the indications for performing CS and factors significantly associated with the rising CS rates was performed using content analysis. A total of 68 studies were included in this review. The most common medical indication for CS was fetal distress, followed by previous CS, antepartum hemorrhage (including placenta previa/abruption), cephalopelvic disproportion, failed induction, hypertensive disorders in pregnancy, oligohydramnios, and non-progress of labor. Maternal request was the most common non-medical indication for conducting CS. Higher maternal age was the most common significant factor associated with the rising CS rate followed by higher maternal education, urban residency, higher economic status, previous CS, pregnancy/childbirth complications, and lower parity/nulliparity. Preference for CS and increasing private number hospital were also factors contributing to the rising rate. Several key indicators and factors significantly associated with rising CS rate are revealed. These key indicators and significant factors reflect the global trend. Reduction in the use of primary CS, unless medically warranted, would help stem rates of CS. Realistic and candid explanation to pregnant women and their families regarding the benefits of vaginal birth for women and babies should form an integral part of maternity care as these are issues of public health

Caesarean section for non-medical reasons: A rising public health issue

Background: Caesarean section (CS) is a life-saving surgical intervention for childbirth. Emphasis is given to perform CS only for valid medical reasons. However, performing CS on non-medical indications is increasing worldwide. The scoping review aims to explore the non-medical reasons for performing CS. Methods: Articles on CS for non-medical reasons were searched using several electronic databases: PubMed, MEDLINE, CINAHL and open access journal databases such as Nepal journals on-line (NepJOL) and Bangladesh journals on-line (BanglaJOL). Additional articles were searched from the reference list of the selected articles and organizational websites. Eligible full-text articles were appraised, and relevant data were extracted. Narrative synthesis of extracted data was performed using a content analysis. Results: Maternal request is the most common non-medical indication of performing CS. The main reason of women’s preference for a CS is to avoid labour pain followed by certainty/convenience, avoid damage pelvic floor and vaginal trauma, and safer for baby. Similarly, the main reason for requesting a CS is fear of labour pain followed by fear of childbirth, safer mode of birth for both mother and baby and maintaining pelvic floor integrity. The main reasons of willingness to perform CS by obstetrician were fear of litigation, financial incentives and convenience. The ethical aspect of non-medically indicated CS remains complex. Conclusions: Performing CS without medical indications is a rising public health issue which has created medical, financial and ethical dilemmas in obstetrics care. The reasons for maternal request for a CS should be explored well. Obstetric care must include education of pregnant women on mode of childbirth including indications, risks and benefits of CS during antenatal visits

Towards active utilisation of community forestry: silvo-institutional model for sustainable forest management in Nepal

This paper explains what we term the ‘silvo-institutional model’ for a more productive, sustainable and equitable management of community forests in Nepal. The paper draws on four years of action research in six research sites of Kavre and Lamjung districts, complemented by the review of silviculture-based forest management by Government of Nepal in various parts of the country. The findings indicate that first, early silviculture-based forest management initiatives have failed because they did not adequately consider the policy and institutional dimensions. Second, current initiatives, while looked promising for the active utilisation of community forests, have faced with complex regulatory and institutional barriers. We argue that a new ‘silvoinstitutional model’, which combines technological and institutional dimensions, has a potential to increase the prospect of successful implementation of silviculture-based forest management.N. S. Paudel, H. Ojha, K. Shrestha, E. Cedamon, R. Karki, G. Paudel, M. Basyal, I. Nuberg and S. Danga

Impact of change in maternal age composition on the incidence of Caesarean section and low birth weight: analysis of delivery records at a tertiary hospital in Tanzania, 1999–2005

<p>Abstract</p> <p>Background</p> <p>Previous studies on change in maternal age composition in Tanzania do not indicate its impact on adverse pregnancy outcomes. We sought to establish temporal changes in maternal age composition and their impact on annual Caesarean section (CS) and low birth weight deliveries (LBWT) at Muhimbili National Hospital in Tanzania.</p> <p>Methods</p> <p>We conducted data analysis of 91,699 singleton deliveries that took place in the hospital between 1999 and 2005. The data were extracted from the obstetric data base. Annual proportions of individual age groups were calculated and their trends over the years studied. Multiple logistic analyses were conducted to ascertain trends in the risks of CS and LBWT. The impact of age composition changes on CS and LBWT was estimated by calculating annual numbers of these outcomes with and without the major changes in age composition, all others remaining equal. In all statistics, a p value < 0.05 was considered significant.</p> <p>Results</p> <p>The proportion of teenage mothers (12–19 years) progressively decreased over time while that of 30–34 years age group increased. From 1999, the risk of Caesarean delivery increased steadily to a maximum in 2005 [adjusted OR = 1.7; 95%CI (1.6–1.8)] whereas that of LBWT declined to a minimum in 2005 (adjusted OR = 0.76; 95% CI (0.71–0.82). The current major changes in age trend were responsible for shifts in the number of CS of up to206 cases per year. Likewise, the shift in LBWT was up to 158 cases per year, but the 30–34 years age group had no impact on this.</p> <p>Conclusion</p> <p>The population of mothers giving birth at MNH is progressively becoming older with substantial impact on the incidence of CS and LBWT. Further research is needed to estimate the health cost implications of this change.</p

Factors associated with antenatal care adequacy in rural and urban contexts-results from two health and demographic surveillance sites in Vietnam

<p>Abstract</p> <p>Background</p> <p>Antenatal Care (ANC) is universally considered important for women and children. This study aims to identify factors, demographic, social and economic, possibly associated with three ANC indicators: number of visits, timing of visits and content of services. The aim is also to compare the patterns of association of such factors between one rural and one urban context in northern Vietnam.</p> <p>Methods</p> <p>Totally 2,132 pregnant women were followed from identification of pregnancy until birth in two Health and Demographic Surveillance Sites (HDSS). Information was obtained through quarterly face to face interviews.</p> <p>Results</p> <p>Living in the rural area was significantly associated with lower adequate use of ANC compared to living in the urban area, both regarding quantity (number and timing of visits) and content. Low education, living in poor households and exclusively using private sector ANC in both sites and self employment, becoming pregnant before 25 years of age and living in poor communities in the rural area turned out to increase the risk for overall inadequate ANC. High risk pregnancy could not be demonstrated to be associated with ANC adequacy in either site. The medical content of services offered was often inadequate, in relation to the national recommendations, especially in the private sector.</p> <p>Conclusion</p> <p>Low education, low economic status, exclusive use of private ANC and living in rural areas were main factors associated with risk for overall inadequate ANC use as related to the national recommendations. Therefore, interventions focussing on poor and less educated women, especially in rural areas should be prioritized. They should focus the importance of early attendance of ANC and sufficient use of core services. Financial support for poor and near poor women should be considered. Providers of ANC should be educated and otherwise influenced to provide sufficient core services. Adherence to ANC content guidelines must be improved through enhanced supervision, particularly in the private sector.</p