Progression of the first stage of spontaneous labour: A prospective cohort study in two sub-Saharan African countries.

BACKGROUND: 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. METHODS AND FINDINGS: 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. CONCLUSIONS: 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

“By slapping their laps, the patient will know that you truly care for her”: A qualitative study on social norms and acceptability of the mistreatment of women during childbirth in Abuja, Nigeria

Background: Many women experience mistreatment during childbirth in health facilities across the world. However, limited evidence exists on how social norms and attitudes of both women and providers influence mistreatment during childbirth. Contextually-specific evidence is needed to understand how normative factors affect how women are treated. This paper explores the acceptability of four scenarios of mistreatment during childbirth. Methods: Two facilities were identified in Abuja, Nigeria. Qualitative methods (in-depth interviews (IDIs) and focus group discussions (FGDs)) were used with a purposive sample of women, midwives, doctors and administrators. Participants were presented with four scenarios of mistreatment during childbirth: slapping, verbal abuse, refusing to help the woman and physical restraint. Thematic analysis was used to synthesize findings, which were interpreted within the study context and an existing typology of mistreatment during childbirth. Results: Eighty-four IDIs and 4 FGDs are included in this analysis. Participants reported witnessing and experiencing mistreatment during childbirth, including slapping, physical restraint to a delivery bed, shouting, intimidation, and threats of physical abuse or poor health outcomes. Some women and providers considered each of the four scenarios as mistreatment. Others viewed these scenarios as appropriate and acceptable measures to gain compliance from the woman and ensure a good outcome for the baby. Women and providers blamed a woman's “disobedience” and “uncooperativeness” during labor for her experience of mistreatment. Conclusions: Blaming women for mistreatment parallels the intimate partner violence literature, demonstrating how traditional practices and low status of women potentiate gender inequality. These findings can be used to facilitate dialogue in Nigeria by engaging stakeholders to discuss how to challenge these norms and hold providers accountable for their actions. Until women and their families are able to freely condemn poor quality care in facilities and providers are held accountable for their actions, there will be little incentive to foster change. Keywords: Maternal health, Childbirth, Mistreatment, Quality of care, Qualitative research, Nigeri

Duration of labour from one level of cervical dilatation to the next by parity and analysis method.

<p>Duration of labour from one level of cervical dilatation to the next by parity and analysis method.</p

The 95th percentiles of cumulative duration of labour in nulliparous women by augmentation.

<p>(A) Survival analysis. (B) Multistate Markov analysis. Thin lines: all women. Thick lines: women with oxytocin augmentation excluded.</p

Average labour curves by parity based on multistate Markov models.

<p>P0, nulliparous women; P1, parity = 1 women; P2+, parity = 2+ women.</p

The 95th percentiles of cumulative duration of labour in parity = 1 women by augmentation.

<p>(A) Survival analysis. (B) Multistate Markov analysis. Thin lines: all women. Thick lines: women with oxytocin augmentation excluded.</p

Labour characteristics and interventions by parity.

<p>Labour characteristics and interventions by parity.</p

Cumulative duration of labour in Para 0, 1, and 2+ based on the cervical dilatation at admission by use of oxytocin augmentation (Markov analysis).

<p>Cumulative duration of labour in Para 0, 1, and 2+ based on the cervical dilatation at admission by use of oxytocin augmentation (Markov analysis).</p

Sample selection flow chart.

<p>* Excluding significant outliers due to unusual rapidity, regression, or inconsistencies with time. BOLD, Better Outcomes in Labour Difficulty.</p

The 95th percentiles of cumulative duration of labour in parity = 2+ women by augmentation.

<p>(A) Survival analysis. (B) Multistate Markov analysis. Thin lines: all women. Thick lines: women with oxytocin augmentation excluded.</p