Assessment of competence for caesarean section with global rating scale

Objective: To establish as reliable and valid the nine-point global rating scale for assessing residents\\u27 independent performance of Caesarean Section. Methods: The validation study was conducted at the Department of Obstetrics and Gynaecology, Aga Khan University Hospital, from April to December 2008, and comprised 15 residents during 40 Caesarean Sections over 9 months. Independently two evaluators rated each procedure and the difficulty of each case. Results: The observations per faculty ranged from 1-8 (mean 4.07± 2.56). The Year 4 residents were observed the most i.e. 32 (40%), followed by Year 3, 30 (37.5%); Year 2; 14 (17.5%); and Year 1, 4 (5%). Mean time required for observation of the surgery was 43.81±14.28 (range: 20-90) with a mode of 45 min. Mean aggregate rating on all items showed gradual progression with the year of residency. The assessment tool had an internal consistency reliability (Cronbach\\u27s alpha) of 0.9097 with low inter-rater reliability. Conclusion: The evaluation tool was found to be reliable and valid for evaluating a resident\\u27s competence for performing Caesarean Section. Training of the assessors is required for a better inter-rater agreement

A review related to midwifery led model of care

Background: Midwifery led care (MLC) is a model of care in which perinatal care is provided to women throughout different phases of childbirth by a midwife. Objective: This paper aims to provide a literature review on MLC. Methods: A variety of databases and reports were considered to do the literature review on MLC. The search was limited from 1991 to 2011 by using keywords. A total of 50 articles were critically appraised for this review. Findings: The main theme that emerged was women ’s satisfaction with MLC. Satisfaction was integrated with midwife ’s presence throughout childbirth, experience to enhance normality in childbirth, cost-effectiveness of MLC, and facilitation of women ’s choice and control during labor. Conclusion: The review concludes that MLC is women-friendly as it considers and respects women’s needs holistically during childbirth

Referral pattern of emergencies in obstetrics: implications for defining scope of services and policy

Objective: To analyse referral pattern of high-risk obstetric cases from secondary to tertiary care hospitals and to assess their maternal and neonatal outcomes. Methods: This retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised all referred obstetric cases from secondary-level hospitals to tertiary-level care within and outside the Hospital between January 2011 and December 2014. Day and time of referral, reason for referral as well as maternal and neonatal outcomes were collected. SPSS 19 was used for data analysis. Results: Of the 634 obstetric referrals, 279(44%) patients were referred to the study site, while 355(56%) sought care in other hospitals. Of those patients who were referred to the AKUH, medical records of 195(69.9%) were available for review. The mean age of the participants was 28±4.7 years. Obstetric complications led to 122(61%) referrals. The top three reasons among these were pregnancy-induced hypertension, preterm labour and foetal causes. Medical causes such as viral infections were the cause of 50(27%) referrals. Moreover, 177(91%) patients were pregnant at the time of referral and the remaining 18(9%) were referred after delivery. Of the pregnant women, 133(75%) delivered at the study site. Caesarean section was the mode in 92(69%) deliveries. There was 1(0.75%) maternal death due to puerperal sepsis while 9(7%) neonatal deaths were recorded. Conclusion: The most common reason for referrals was obstetric indications. Moreover, a quarter of referrals were initiated due to medical conditions, most of which were due to infections

Community\u27s perceptions of pre-eclampsia and eclampsia in Sindh Pakistan: A qualitative study

Background: Maternal mortality is of global public health concern and \u3e99% of maternal deaths occur in less developed countries. The common causes of direct maternal death are hemorrhage, sepsis and pre-eclampsia/eclampsia. In Pakistan, pre-eclampsia/eclampsia deaths represents one-third of maternal deaths reported at the tertiary care hospital settings. This study explored community perceptions, and traditional management practices about pre-eclampsia/eclampsia.Methods: A qualitative study was conducted in Sindh Province of Pakistan from February to July 2012. Twenty-six focus groups were conducted, 19 with women of reproductive age/mothers-in-law (N=173); and 7 with husbands/fathers-in-law (N=65). The data were transcribed verbatim in Sindhi and Urdu, then analyzed for emerging themes and sub-themes using NVivo version 10 software.Results: Pre-eclampsia in pregnancy was not recognized as a disease and there was no name in the local languages to describe this. Women however, knew about high blood pressure and were aware they can develop it during pregnancy. It was widely believed that stress and weakness caused high blood pressure in pregnancy and it caused symptoms of headache. The perception of high blood pressure was not based on measurement but on symptoms. Self-medication was often used for headaches associated with high blood pressure. They were also awareness that severely high blood pressure could result in death.Conclusions: Community-based participatory health education strategies are recommended to dispel myths and misperceptions regarding pre-eclampsia and eclampsia. The educational initiatives should include information on the presentation, progression of illness, danger signs associated with pregnancy, and appropriate treatment

The feasibility of community level interventions for pre-eclampsia in South Asia and sub-saharan Africa: A mixed-methods design

Background: Globally, pre-eclampsia and eclampsia are major contributors to maternal and perinatal mortality; of which the vast majority of deaths occur in less developed countries. In addition, a disproportionate number of morbidities and mortalities occur due to delayed access to health services. The Community Level Interventions for Pre-eclampsia (CLIP) Trial aims to task-shift to community health workers the identification and emergency management of pre-eclampsia and eclampsia to improve access and timely care. Literature revealed paucity of published feasibility assessments prior to initiating large-scale community-based interventions. Arguably, well-conducted feasibility studies can provide valuable information about the potential success of clinical trials prior to implementation. Failure to fully understand the study context risks the effective implementation of the intervention and limits the likelihood of post-trial scale-up. Therefore, it was imperative to conduct community-level feasibility assessments for a trial of this magnitude.Methods: A mixed methods design guided by normalization process theory was used for this study in Nigeria, Mozambique, Pakistan, and India to explore enabling and impeding factors for the CLIP Trial implementation. Qualitative data were collected through participant observation, document review, focus group discussion and in-depth interviews with diverse groups of community members, key informants at community level, healthcare providers, and policy makers. Quantitative data were collected through health facility assessments, self-administered community health worker surveys, and household demographic and health surveillance.Results: Refer to CLIP Trial feasibility publications in the current and/or forthcoming supplement.Conclusions: Feasibility assessments for community level interventions, particularly those involving task-shifting across diverse regions, require an appropriate theoretical framework and careful selection of research methods. The use of qualitative and quantitative methods increased the data richness to better understand the community contexts

Clinical governance in the management of induction of labour

Objective: To determine whether dissemination of explicit guidelines, developed in consensus with stakeholders, for the processes of induction of labour (IOL), results in reduction of variability in clinical practice.Design: A prospective behaviour modification interventional study.PLACE AND DURATION OF STUDY: The study was conducted in the department of Obstetrics and Gynaecology at the Aga Khan University, Karachi, between January 1 and August 31, 2002.SUBJECTS AND Methods: In a total of 142 conveniently sampled women, undergoing IOL, pre-identified quality assessment indicators were measured. After collection of data from initial 71-women (pre-intervention group) mutually agreed guidelines for clinical practice were disseminated, over a period of time, among consultants, residents and nurses. These indicators were again measured in subsequent 71 women (post-intervention group) to evaluate magnitude of residual non-conformities in these processes.Results: Following behaviour modification interventions, nonconformities in consultants and residents-dependent processes like timely review of patients by consultants (72 vs 1.4%, p value \u3c0.0001), documentation of indication for IOL (66.2 vs 16.9%, p value \u3c0.0001), method of induction for IOL (56.3 vs 28.2%, p value 0.0001), and calculation of Bishop score before IOL (38.0 vs 4.2 %, p value \u3c0.0001) were significantly reduced.CONCLUSION: Dissemination of explicit guidelines developed in consensus with stakeholders significantly reduces variability in clinical practice. Our model can be used for improving quality of care in other areas of obstetric health care

Perinatal women\u27s perceptions about midwifery led model of care in secondary care hospitals in Karachi, Pakistan

Objective: The purpose of this study was to explore the perceptions and experiences of perinatal women who have availed of midwifery led model of care (MLC) at secondary care settings in Karachi, Pakistan. Design: A qualitative descriptive exploratory approach using semi-structured interviews. Participants: A purposive sample of 10 women who had used MLC was enroled from each site. Findings: Content analysis highlighted that ‘women\u27s satisfaction with MLC’ emerged as the main theme and, under this theme, the six categories that emerged were: (1) the admired capability and maturity of midwives, (2) the affordability of midwifery services, (3) a personalised relationship, (4) the empowerment of women to make decisions, (5) presence, and (6) a voiced concern regarding lack of marketing of MLC. Key conclusions: The study findings revealed that women had an overall feeling of satisfaction with the maternity care provided by the midwives. Mostly, women appreciated the midwives\u27 expertise in providing maternity care. Majority of the women acknowledged the continuous presence of the midwives during childbirth and the women shared that they were empowered to make decisions related to their care. Most of the women indicated that marketing for MLC is scarce and insufficient. Majority of the women are even not aware of this model; therefore, it is imperative to create awareness and to provide MLC access to women through robust marketing. Implications for practice: The findings of this study may help to advocate and provide women-friendly maternity care, by giving choice and control to women during childbirth, providing comfort to women by using fewer medical interventions, and promoting normality by attending spontaneous vaginal childbirths

Health care seeking behaviours in pregnancy in rural Sindh, Pakistan: a qualitative study

Background: Pakistan has alarmingly high numbers of maternal mortality along with suboptimal care-seeking behaviour. It is essential to identify the barriers and facilitators that women and families encounter, when deciding to seek maternal care services. This study aimed to understand health-seeking patterns of pregnant women in rural Sindh, Pakistan. Methods: A qualitative study was undertaken in rural Sindh, Pakistan as part of a large multi-country study in 2012. Thirty three focus group discussions and 26 in-depth interviews were conducted with mothers [n = 173], male decision-makers [n = 64], Lady Health Workers [n = 64], Lady Health Supervisors [n = 10], Women Medical Officers [n = 9] and Traditional Birth Attendants [n = 7] in the study communities. A set of a priori themes regarding care-seeking during pregnancy and its complications as well as additional themes as they emerged from the data were used for analysis. Qualitative analysis was done using NVivo version 10. Results: Women stated they usually visited health facilities if they experienced pregnancy complications or danger signs, such as heavy bleeding or headache. Findings revealed the importance of husbands and mothers-in-law as decision makers regarding health care utilization. Participants expressed that poor availability of transport, financial constraints and the unavailability of chaperones were important barriers to seeking care. In addition, private facilities were often preferred due to the perceived superior quality of services. Conclusion: Maternal care utilization was influenced by social, economic and cultural factors in rural Pakistani communities. The perceived poor quality care at public hospitals was a significant barrier for many women in accessing health services. If maternal lives are to be saved, policy makers need to develop processes to overcome these barriers and ensure easily accessible high-quality care for women in rural communities. Trial Registration NCT01911494Medicine, Faculty ofOther UBCNon UBCObstetrics and Gynaecology, Department ofReviewedFacult

The feasibility of community level interventions for pre-eclampsia in South Asia and Sub-Saharan Africa: a mixed-methods design

Background: Globally, pre-eclampsia and eclampsia are major contributors to maternal and perinatal mortality; of which the vast majority of deaths occur in less developed countries. In addition, a disproportionate number of morbidities and mortalities occur due to delayed access to health services. The Community Level Interventions for Pre-eclampsia (CLIP) Trial aims to task-shift to community health workers the identification and emergency management of pre-eclampsia and eclampsia to improve access and timely care. Literature revealed paucity of published feasibility assessments prior to initiating large-scale community-based interventions. Arguably, well-conducted feasibility studies can provide valuable information about the potential success of clinical trials prior to implementation. Failure to fully understand the study context risks the effective implementation of the intervention and limits the likelihood of post-trial scale-up. Therefore, it was imperative to conduct community-level feasibility assessments for a trial of this magnitude. Methods: A mixed methods design guided by normalization process theory was used for this study in Nigeria, Mozambique, Pakistan, and India to explore enabling and impeding factors for the CLIP Trial implementation. Qualitative data were collected through participant observation, document review, focus group discussion and in-depth interviews with diverse groups of community members, key informants at community level, healthcare providers, and policy makers. Quantitative data were collected through health facility assessments, self-administered community health worker surveys, and household demographic and health surveillance. Results: Refer to CLIP Trial feasibility publications in the current and/or forthcoming supplement. Conclusions: Feasibility assessments for community level interventions, particularly those involving task-shifting across diverse regions, require an appropriate theoretical framework and careful selection of research methods. The use of qualitative and quantitative methods increased the data richness to better understand the community contexts. Trial registration NCT01911494Medicine, Faculty ofOther UBCNon UBCObstetrics and Gynaecology, Department ofReviewedFacult