The utility of clinical care pathways in determining perinatal outcomes for women with one previous caesarean section; a retrospective service evaluation

<p>Abstract</p> <p>Background</p> <p>The rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri. Subsequent pregnancies in these women are risk-prone and may complicate. Besides ensuring standardised management, care pathways could be used to evaluate for perinatal outcomes in these high risk pregnancies. We aim to demonstrate the use of a care pathway for vaginal birth after caesarean section as a service evaluation tool to determine perinatal outcomes.</p> <p>Methods</p> <p>A retrospective service evaluation by review of delivery case notes and records was undertaken at the Aga Khan University Hospital, Nairobi, Kenya between January 2008 and December 2009</p> <p>Women with ≥2 previous caesarean sections, previous classical caesarean section, multiple gestation, breech presentation, severe pre-eclampsia, transverse lie, placenta praevia, conditions requiring induction of labour and incomplete records were excluded. Outcome measures included the proportion of eligible women who opted for test of scar (ToS), success rate of vaginal birth after caesarean section (VBAC); proportion on women opting for elective repeat caesarean section (ERCS) and their perinatal outcomes.</p> <p>Results</p> <p>A total of 215 women with one previous caesarean section were followed up using a standard care pathway. The median parity (minimum-maximum) was 1.0<abbrgrp><abbr bid="B1">1</abbr><abbr bid="B2">2</abbr><abbr bid="B3">3</abbr><abbr bid="B4">4</abbr></abbrgrp>. The other demographic characteristics were comparable. Only 44.6% of eligible mothers opted to have a ToS. The success rate for VBAC was 49.4% with the commonest (31.8%) reason for failure being protracted active phase of labour. Maternal morbidity was comparable for the failed and successful VBAC group. The incidence of hemorrhage was 2.3% and 4.4% for the successful and failed VBAC groups respectively. The proportion of babies with acidotic arterial PH (< 7.10) was 3.1% and 22.2% among the successful and failed VBAC groups respectively. No perinatal mortality was reported.</p> <p>Conclusions</p> <p>Besides ensuring standardised management, care pathways could be objective audit and service evaluation tools for determining perinatal outcomes.</p

Power and poverty: A participatory study on the complexities of HIV and intimate partner violence in an informal urban settlement in Nairobi, Kenya

People in informal urban settlements in Kenya face multiple inequalities, yet researchers investigate issues such as HIV or intimate partner violence (IPV) in isolation, targeting single populations and focusing on individual behaviour, without involving informal settlement dwellers. We formed a study team of researchers (n = 4) and lay investigators (n = 11) from an informal settlement in Nairobi, Kenya to understand the power dynamics in the informal urban settlement that influence vulnerability to IPV and HIV among women and men from key populations in this context. We facilitated participatory workshops with 56 women and 32 men from different marginalised groups and interviewed 10 key informants. We used a participatory data analysis approach. Our findings suggest the IPV and HIV nexus is rooted in the daily struggle for cash and survival in the informal settlement where lucrative livelihoods are scarce and a few gatekeepers regulate access to opportunities. Power is gendered and used to exercise control over people and resources. Common coping strategies applied to mitigate against the effects of poverty and powerlessness amplify vulnerabilities to HIV and IPV. These complex power relations create and sustain an environment conducive to IPV and HIV. Prevention interventions thus need to address underlying structural drivers, uphold human rights, create safe environments, and promote participation to maximise and sustain the positive effects of biomedical, behavioural, and empowerment strategies