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Background: Professional societies such as the American College of Obstetricians and Gynecologists (ACOG) promote the idea that postpartum care is an ongoing process where there is adequate opportunity to provide services and support. Nonetheless, in practice, the guidelines ask clinicians to perform more clinical responsibilities than they might be able to do with limited time and resources., Methods: We conducted an online survey among practicing obstetric clinicians (obstetrician/gynecologists (OB/GYNs), midwives, and family medicine doctors) in California about their priorities and care practices for the first postpartum visit and explored how they prioritize multiple clinical responsibilities within existing time and resources. Between September 2023 and February 2024, 174 out of 229 eligible participants completed the survey, a 76% response rate. From a list of care components, we used descriptive statistics to identify those that were highly prioritized by most clinicians and those that were considered a priority by very few and examined the alignment between prioritized components and recommended care practices., Results: Clinicians were highly invested in the care components that they rated as most important, indicating that they always check these components or assess them when they perceive patient need. Depression and anxiety, breast health/breast feeding issues, vaginal birth complications and family planning counseling were highly ranked components by all clinicians. In contrast, clinicians more often did not assess those care components that infrequently ranked highly among the priority listing, consisting mainly of social drivers of health such as screening and counseling for intimate partner violence, working conditions and food/housing insecurity. In both instances, we found little discordance between priorities and care practices. However, OB/GYNs and midwives differed in some care components that they prioritized highly., Conclusions: While there is growing understanding of how important professional society recommendations are for maternal-infant health, clinicians face barriers completing all recommendations, especially those components related to social drivers of health. However, what the clinicians do prioritize highly, they are likely to perform. Now that Medi-Cal (Medicaid) insurance is available in California for up to 12 months postpartum, there is a need to understand what care clinicians provide and what gaps remain., (© 2024. The Author(s).)

Objective: This document addresses the clinical application of next-generation sequencing (NGS) technologies for prenatal genetic diagnosis and aims to establish clinical practice recommendations in Spain to ensure uniformity in implementing these technologies into prenatal care., Methods: A joint committee of expert obstetricians and geneticists was created to review the existing literature on fetal NGS for genetic diagnosis and to make recommendations for Spanish healthcare professionals., Results: This guideline summarises technical aspects of NGS technologies, clinical indications in prenatal setting, considerations regarding findings to be reported, genetic counselling considerations as well as data storage and protection policies., Conclusions: This document provides updated recommendations for the use of NGS diagnostic tests in prenatal diagnosis. These recommendations should be periodically reviewed as our knowledge of the clinical utility of NGS technologies, applied during pregnancy, may advance., Competing Interests: Competing interests: MG-H works in NIMGenetics, a private genetics lab currently performing prenatal NGS., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The Rural Surgical Obstetrical Networks (RSON) initiative in BC was developed to stabilize and grow low volume rural surgical and obstetrical services. One of the wrap-around supportive interventions was funding for Continuous Quality Improvement (CQI) initiatives, done through a local provider-driven lens. This paper reviews mixed-methods findings on providers' experiences with CQI and the implications for service stability., Background: Small, rural hospitals face barriers in implementing quality improvement initiatives due primarily to lack of resource capacity and the need to prioritize clinical care when allocating limited health human resources. Given this, funding and resources for CQI were key enablers of the RSON initiative and seen as an essential part of a response to assuaging concerns of specialists at higher volume sites regarding quality in lower volume settings., Methods: Data were derived from two datasets: in-depth, qualitative interviews with rural health care providers and administrators over the course of the RSON initiative and through a survey administered at RSON sites in 2023., Findings: Qualitative findings revealed participants' perceptions of the value of CQI (including developing expanded skillsets and improved team function and culture), enablers (the organizational infrastructure for CQI projects), challenges in implementation (complications in protecting/prioritizing CQI time and difficulty with staff engagement) and the importance of local leadership. Survey findings showed high ratings for elements of team function that relate directly to CQI (team process and relationships)., Conclusion: Attention to effective mechanisms of CQI through a rural lens is essential to ensure that initiatives meet the contextual realities of low-volume sites. Instituting pathways for locally-driven quality improvement initiatives enhances team function at rural hospitals through creating opportunities for trust building and goal setting, improving communication and increasing individual and team-wide motivation to improve patient care., Competing Interests: Sean Ebert received sessional funding from the Rural Coordination Centre of BC (RCCbc) in his role as medical lead for the Quality Improvement Pillar for the Rural Surgical and Obstetrical Networks (RSON) initiative. In his capacity as medical lead he received funding to travel to the rural communities where the participants we report on in this manuscript work and provide care. Tom Skinner is employed by the Rural Coordination Centre of BC (RCCbc) as the Project Manager of the RSON Initiative. The findings reported in the survey are part of the evaluation of RSON. As an employee, his travel to the rural communities were covered because he was supporting hospital teams in implementing the PROES survey and interpreting the result. Kim Williams received salary funding from the Rural Coordination Centre of BC (RCCbc) in her capacity as administrative co-lead for the Rural Surgical and Obstetrical Networks (RSON) initiative. She received funding to travel to the rural communities where the participants whom we report on in this manuscript work and provide care. Nancy Humber received funding from the Rural Coordination Centre of BC (RCCbc) in her role as a clinical lead for the Rural Surgical Obstetrical Network. In her capacity as a clinical lead, she received funding for travel to the rural communities where the participants whom we report on in this manuscript work and provide care. All other authors are part of the RSON evaluation team at the University of British Columbia, Canada and have no conflicts of interest to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Kornelsen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Little is known about the care provided following positive depression screens in obstetrics and gynecology (Ob/Gyn) patients., Method: This study evaluated documented care plans and outcomes for 445 Ob/Gyn patients with positive depression screens between January 2018 and December 2020. Logistic regression models were estimated to identify predictors of changes in documented care plans and to test if a documented plan was associated with a reduction in depression severity in 6 months., Results: The sample consisted of 445 patients who were on average 35.5 ( SD = 12.8) years; 206 (46.3%) were White and 178 (40.0%) were Black. A total of 64 (14.4%) had a depression care plan documenting antidepressant initiation or change and/or psychotherapy referral. Relative to those aged 18-29, patients 40 or older had approximately 60% lower odds of a documented care plan change ( OR = 0.394; p < .05). Relative to those seen by nurses, patients seen by physicians had approximately 70% lower odds of having treatment change ( OR = 0.282; p < .05). Patients with a depression care plan documented had approximately 2.7 times higher odds of achieving 50% or more reduction in their Patient Health Questionnaire-9 depression severity score than those without a documented plan ( OR = 2.685; p = .009)., Discussion: While most patients did not experience an initiation or change in their depression care plan on the same day as their positive screen, those patients with a plan documented showed significantly more improvement than those who did not. Standardized recommendations may improve depression outcomes among patients with positive depression screens. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Triaging of obstetric patients by emergency care providers is paramount. It helps provide appropriate and timely management to prevent further injury and complications. Standardised trauma acuity scales have limited applicability in obstetric triage. Specific obstetric triage index tools improve maternal and neonatal outcomes but remain underused. The aim was to introduce a validity-tested obstetric triage tool to improve the percentage of correctly triaged patients (correctly colour-coded in accordance with triage index tool and attended to within the stipulated time interval mandated by the tool) from the baseline of 49% to more than 90% through a quality improvement (QI) process.A team of nurses, obstetricians and postgraduates did a root cause analysis to identify the possible reasons for incorrect triaging of obstetric patients using process flow mapping and fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles to address issues identified.The interventions included introduction and application of an obstetric triage index tool, training of triage nurses and residents. We implemented these interventions in eight PDSA cycles and observed outcomes by using run charts. A set of process, output and outcome indicators were used to track if changes made were leading to improvement.Proportion of correctly triaged women increased from the baseline of 49% to more than 95% over a period of 8 months from February to September 2020, and the results have been sustained in the last PDSA cycle, and the triage system is still sustained with similar results. The median triage waiting time reduced from the baseline of 40 min to less than 10 min. There was reduction in complications attributable to improper triaging such as preterm delivery, prolonged intensive care unit stay and overall morbidity. It can be thus concluded that a QI approach improved obstetric triaging in a rural maternity hospital in India., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Delineate the scope of teleconsultation services that can be effectively performed to provide women with comprehensive gynaecological and obstetrical care., Design: Based on the literature and experts' insights, we identified a list of gynaecological and obstetrical care practices suitable for teleconsultation. A three-round Delphi consensus survey was then conducted online among a panel of French experts. Experts using a 9-point Likert scale assessed the relevance of each teleconsultation practice in four key domains: prevention, gynaecology and antenatal and postnatal care. Consensus was determined by applying a dual-criteria approach: the median score on a 9-point Likert scale and the percentage of votes either below 5 or 5 and higher., Setting: The study was conducted at a national level in France and involved multiple healthcare centres and professionals from various geographical locations., Participants: The panel comprised 22 French experts with 19 healthcare professionals, including 12 midwives, 3 obstetricians-gynaecologists, 4 general practitioners and 3 healthcare system users. Participants were selected to include diverse practice settings encompassing hospital and private practices in both rural and urban areas., Primary and Secondary Outcome Measures: The study's primary outcome was the identification of gynaecological and obstetrical care practices suitable for teleconsultation. Secondary outcomes included the level of professional consensus on these practices., Results: In total, 71 practices were included in the Delphi survey. The practices approved for teleconsultation were distributed as follows: 92% in prevention (n=12/13), 55% in gynaecology (n=18/33), 31% in prenatal care (n=5/16) and 12% in postnatal care (n=1/9). Lastly, 10 practices remained under discussion: 7 in gynaecology, 2 in prenatal care and 1 in postnatal care., Conclusions: Our consensus survey highlights both the advantages and limitations of teleconsultations for women's gynaecological and obstetrical care, emphasising the need for careful consideration and tailored implementation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general anesthesia than in the non-obstetric population. The inability to ventilate and oxygenate is one of the most common causes of morbidity and mortality associated with general anesthesia for cesarean section. The aim of this paper is to present and analyze modern guidelines and algorithms for the management of difficult airway in obstetrics as an important segment of anesthesiology practice. Modern difficult airway management guidelines for pregnant women describe the procedure of difficult facemask ventilation, difficult airway management by using supraglottic devices, difficult endotracheal intubation, and emergency cricothyrotomy or tracheotomy in a situation where oxygenation and ventilation are impossible. Algorithms describe the procedures and equipment for each variant of difficult airway and decision-making strategies in situations when neither airway nor adequate oxygenation can be provided. Croatian anesthesiologists in most obstetric departments have appropriate equipment, as well as necessary experience in difficult airway management for pregnant women, and modern algorithms from the most developed countries can be adopted and accommodated to our daily practice, as well as incorporated into the training curricula of residents., (Sestre Milosrdnice University Hospital.)

Introduction: Mistreatment, discrimination, and poor psycho-social support during childbirth at health facilities are common in lower- and middle-income countries. Despite a policy directive from the World Health Organisation (WHO), no operational model exists that effectively demonstrates incorporation of these guidelines in routine facility-based maternity services. This early-phase implementation research aims to develop, implement, and test the feasibility of a service-delivery strategy to promote the culture of supportive and dignified maternity care (SDMC) at public health facilities., Methods: Guided by human-centred design approach, the implementation of this study will be divided into two phases: development of intervention, and implementing and testing feasibility. The service-delivery intervention will be co-created along with relevant stakeholders and informed by contextual evidence that is generated through formative research. It will include capacity-building of maternity teams, and the improvement of governance and accountability mechanisms within public health facilities. The technical content will be primarily based on WHO's intrapartum care guidelines and mental health Gap Action Programme (mhGAP) materials. A mixed-method, pre-post design will be used for feasibility assessment. The intervention will be implemented at six secondary-level healthcare facilities in two districts of southern Sindh, Pakistan. Data from multiple sources will be collected before, during and after the implementation of the intervention. We will assess the coverage of the intervention, challenges faced, and changes in maternity teams' understanding and attitude towards SDMC. Additionally, women's maternity experiences and psycho-social well-being-will inform the success of the intervention., Expected Outcomes: Evidence from this implementation research will enhance understanding of health systems challenges and opportunities around SDMC. A key output from this research will be the SDMC service-delivery package, comprising a comprehensive training package (on inclusive, supportive and dignified maternity care) and a field tested strategy to ensure implementation of recommended practices in routine, facility-based maternity care. Adaptation, Implementation and evaluation of SDMC package in diverse setting will be way forward. The study has been registered with clinicaltrials.gov (Registration number: NCT05146518)., Competing Interests: The authors have declared that no competing interests exist.

Background: Diabetes in pregnancy is associated with an increased risk to the woman and to the developing fetus. Currently, there is no consensus on the optimal management strategies for the follow-up and the timing of delivery of pregnancies affected by gestational and pregestational diabetes, with different international guidelines suggesting different management options., Materials and Methods: We conducted a retrospective cohort study from January 2017 to January 2021, to compare maternal and neonatal outcomes of pregnancies complicated by gestational and pregestational diabetes, followed-up and delivered in a third level referral center before and after the introduction of a standardized multidisciplinary management protocol including diagnostic, screening, and management criteria., Results: Of the 131 women included, 55 were managed before the introduction of the multidisciplinary management protocol and included in group 1 (preprotocol), while 76 were managed according to the newly introduced multidisciplinary protocol and included in group 2 (after protocol). We observed an increase in the rates of vaginal delivery, rising from 32.7% to 64.5% (<0.001), and the rate of successful induction of labor improved from 28.6% to 86.2% ( P < 0.001). No differences were found in neonatal outcomes, and the only significant difference was demonstrated for the rates of fetal macrosomia (20% versus 5.3%, P : 0.012). Therefore, the improvements observed in the maternal outcomes did not impact negatively on fetal and neonatal outcomes., Conclusion: The introduction of a standardized multidisciplinary management protocol led to an improvement in the rates of vaginal delivery and in the rate of successful induction of labor in our center. A strong cooperation between obstetricians, diabetologists, and neonatologists is crucial to obtain a successful outcome in women with diabetes in pregnancy., Competing Interests: All the authors declare no conflicts of interest., (Copyright © 2021 Maddalena Morlando et al.)

Objective: The Nuchal Translucency Quality Review (NTQR) program has provided standardized education, credentialing and epidemiological monitoring of nuchal translucency (NT) measurements since 2005. Our aim was to review the effect on NT measurement of provider characteristics since the program's inception., Methods: We evaluated the distribution of NT measurements performed between January 2005 and December 2019, for each of the three primary performance indicators of NT measurement (NT median multiples of the median (MoM), SD of log 10 NT MoM and slope of NT with respect to crown-rump length (CRL)) for all providers within the NTQR program with more than 30 paired NT/CRL results. Provider characteristics explored as potential sources of variability included: number of NT ultrasound examinations performed annually (annual scan volume of the provider), duration of participation in the NTQR program, initial credentialing by an alternative pathway, provider type (physician vs sonographer) and number of NT-credentialed providers within the practice (size of practice). Each of these provider characteristics was evaluated for its effect on NT median MoM and geometric mean of the NT median MoM weighted for the number of ultrasound scans, and multiple regression was performed across all variables to control for potential confounders., Results: Of 5 216 663 NT measurements from 9340 providers at 3319 sites, the majority (75%) of providers had an NT median MoM within the acceptable range of 0.9-1.1 and 85.5% had NT median MoM not statistically significantly outside this range. Provider characteristics associated with measurement within the expected range of performance included higher volume of NT scans performed annually, practice at a site with larger numbers of other NT-credentialed providers, longer duration of participation in the NTQR program and alternative initial credentialing pathway., Conclusions: Annual scan volume, duration of participation in the NTQR program, alternative initial credentialing pathway and number of other NT-credentialed providers within the practice are all associated with outcome metrics indicating quality of performance. It is critical that providers participate in ongoing quality assessment of NT measurement to maintain consistency and precision. Ongoing assessment programs with continuous feedback and education are necessary to maintain quality care. © 2021 International Society of Ultrasound in Obstetrics and Gynecology., (© 2021 International Society of Ultrasound in Obstetrics and Gynecology.)

Background: In maternity services, as in other areas of healthcare, increasing emphasis is placed on improving "efficiency" or "productivity". The first step in any efficiency and productivity analysis is the selection of relevant input and output measures. Within healthcare quantifying what is produced (outputs) can be difficult. The aim of this paper is to identify a potential output measure, that can be used in an assessment of the efficiency and productivity of labour and birth in-hospital care in Australia and to assess the extent to which it reflects the principles of woman-centred care., Methods: This paper will survey available perinatal and maternal datasets in Australia to identify potential output measures; map identified output variables against the principles of woman-centred care outlined in Australia's national maternity strategy; and based on this, create a preliminary composite outcome measure for use in assessing the efficiency and productivity of Australian maternity services., Results: There are significant gaps in Australia's maternity data collections with regard to measuring how well a maternity service is performing against the values of respect, choice and access; however safety is well measured. Our proposed composite measure identified that of the 63,215 births in Queensland in 2014, 67% met the criteria of quality outlined in our composite measure., Conclusions: Adoption in Australia of the collection of woman-reported maternity outcomes would substantially strengthen Australia's national maternity data collections and provide a more holistic view of pregnancy and childbirth in Australia beyond traditional measure of maternal and neonate morbidity and mortality. Such measures to capture respect, choice and access could complement existing safety measures to inform the assessment of productivity and efficiency in maternity care., (© 2021. The Author(s).)

Objective: The aim of this national study was to examine the incidence of preterm pre-eclampsia (PE) and the proportion of women with risk factors for PE, according to the criteria suggested by the National Institute for Health and Care Excellence (NICE) and the American College of Obstetricians and Gynecologists (ACOG), during a 10-year period in Denmark., Methods: Data from The Danish National Patient Registry and the Danish Medical Birth Registry were used to obtain the incidence of preterm PE with delivery < 37 weeks' gestation and risk factors for PE for all deliveries in Denmark from 1 January 2008 to 31 December 2017. The proportion of women with at least one high-risk factor and/or at least two moderate-risk factors for PE, according to the NICE and ACOG criteria, and the detection rate for preterm PE were examined. Race, socioeconomic status and the woman's weight at birth were not available from the registries used, and information on Type-2 diabetes was found to be invalid., Results: Of the 597 492 deliveries during the study period, any PE was registered in 3.2%, preterm PE < 37 weeks in 0.7% and early-onset PE < 34 weeks' gestation in 0.3%. These proportions remained largely unchanged from 2008 to 2017. Overall, the NICE criteria were fulfilled in 7.5% of deliveries and the ACOG criteria in 17.3%. In the total population, the NICE criteria identified 47.6% of those with preterm PE and the ACOG criteria identified 60.5%. The current criteria for offering aspirin treatment in Denmark largely correspond to having at least one NICE high-risk factor. In 2017, a total of 3.5% of deliveries had at least one NICE high-risk factor, which identified 28.4% of cases that later developed preterm PE., Conclusions: The incidence of preterm PE remained largely unchanged in Denmark from 2008 to 2017. Prediction of PE according to high-risk maternal factors could be improved by addition of moderate-risk factors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology., (© 2021 International Society of Ultrasound in Obstetrics and Gynecology.)

Introduction: the use of ultrasound is one of the most vital tools in the management of pregnancies and contributes significantly in improving maternal and child health. Certain indications in pregnancy, guide the obstetrician as to which obstetric scan deems appropriate. The full realization of the benefits of ultrasound depends on whether it is being used appropriately or not, and hence this study aimed at auditing for the appropriate indications for obstetric ultrasound., Methods: a review of all request forms for obstetric scan between June 2019 and July 2020 was performed to assess the appropriateness of requests for obstetric ultrasound at the Cape Coast Teaching Hospital. The data obtained was analyzed using SPSS (SPSS Inc. Chicago, IL version 20.0). A Chi-squared test of independence was used to check for statistically significant differences between variables at p ≤ 0.05., Results: three hundred and fourteen (314) out of the 527 request forms had clinical indications stated. 174 (81.7%) of requests from Cape Coast Teaching Hospital and 39 (18.3%) from other health centers did not indicate patients clinical history/indication on the request forms. Majority 76 (68.5%) of scans in the first trimester were done without indications/history. Only 29 of requests with clinical history were inappropriate., Conclusion: practitioners should be mindful of adequately completing request forms for obstetric investigations since a large number of practitioners do not state the history/indications for the scans. There should be continuous medical education on the importance of appropriate indication for obstetric ultrasound., Competing Interests: The authors declare no competing interests., (Copyright: Emmanuel Kobina Mesi Edzie et al.)

Competing Interests: Intérêts concurrents: Iris Gorfinkel déclare avoir reçu des subventions de GSK, Merck, Urovant Sciences et Johnson & Johnson. Entre 1991 et 1995, la Dre Gorfinkel a reçu des honoraires en tant que médecin experte appelée à témoigner pour un centre de services aux victimes d’agressions sexuelles qui relevait de l’Hôpital Shaughnessy et ensuite de l’Hôpital pour femmes de la Colombie-Britannique. La Dre Gorfinkel a aussi reçu des honoraires en tant que conférencière pour GSK, CME Outfitters et Doctors Nova Scotia; elle détient des actions de Johnson & Johnson et de Merck et a été coprésidente d’un comité consultatif sur Shingrix (GSK). La Dre Gorfinkel a participé, parfois contre rémunération, à des projets de rédaction et de présentations médicales pour la radio et la télévision de la CBC, Zoomer Radio and Television, Global News, CTV News, Bored Panda, The Globe and Mail, le JAMC et Le Médecin de famille canadien. Aucun autre intérêt concurrent n’a été déclaré.

Background: Obesity is associated with the development of polycystic ovary syndrome (PCOS) and contributes substantially to metabolic abnormalities in women with PCOS. The study aimed to describe and compare the practices of physicians in the diagnosis, evaluation, and treatment of obesity in patients with PCOS., Methods: Reproductive endocrinologists (Repro-Endo) and obstetrician-gynecologists (non-reproductive medicine specialty, OB-Gyn) in China participated in a survey, and their responses were analyzed using χ 2 tests, Fisher exact tests, and multivariable logistic regression analysis., Results: The study analyzed 1318 survey responses (85.8% OB-Gyn; 97.3% women). Body mass index was the most common diagnostic criterion for obesity; only 1.3% of participants measured waist circumference to identify abdominal obesity. More Repro-Endo participants (25% of all participants) enquired about the psychological problems of patients with obesity than OB-Gyn participants, and 42.5% of participants reported ordering both a lipid profile and oral glucose tolerance test (OGTT) for patients with obesity and PCOS. Multivariable analysis, that included physician's specialty, age, hospital grade, and number of patients with PCOS seen annually, revealed that OB-Gyn participants were less likely to order OGTT (OR, 0.3; 95% CI, 0.2-0.4) and lipid profile (OR, 0.2; 95% CI, 0.1-0.3) than Repro-Endo participants. The most common treatments for patients with PCOS were lifestyle modification (> 95%) and metformin (> 80%). More Repro-Endo participants prescribed metformin at a dose of 1.5 g/day compared with OB-Gyn (47.6% vs. 26.3%), and more OB-Gyn participants reported being unclear about the appropriate dosage of metformin for patients with obesity and PCOS (8.9% vs. 1.6%)., Conclusion: Our survey identified knowledge gaps in metabolic screening for patients with obesity and PCOS and a disparity in the evaluation and treatment of obesity in PCOS among different specialties. Similarly, it highlights the need to improve obesity management education for physicians caring for women with PCOS., (© 2021. The Author(s).)

Objectives: Cerclage operation is one of the most common obstetric controversies. The aim of this study was to compare the perinatal outcomes and placental inflammation of cerclage performed adherent and non-adherent to international guidelines., Material and Methods: This study included all consecutive women with singleton deliveries who underwent cerclage. According to the current American College of Obstetricians and Gynecologists (ACOG) guideline, we designated our study population into two groups: the adherent-to-guideline and non-adherent groups. Each group was categorized into two groups according to cervical length (CL) at the time of cerclage (<2.0 cm vs. ≥2.0 cm). We evaluated the reasons for cerclage, maternal characteristics, perioperative variables, pregnancy and neonatal outcomes, and placental inflammatory pathology according to the criteria proposed by the Society of Pediatric Pathology., Results: Among 310 women with cerclage, we excluded patients (n = 21) with indicated preterm delivery (PTD), major fetal anomaly, fetal death in-utero, and missing information for reason of cerclage. We also excluded patients who underwent physical examination-indicated cerclage (n = 53) and with missing information of CL at the time of cerclage (n = 52). A total of 184 women were eventually analyzed. In women with CL < 2.0 cm, the non-adherent group showed similar PTD (<28 weeks, <34 weeks) and neonatal composite morbidity rates compared to the adherent-to-guideline group. However, in women with CL ≥ 2.0 cm, the non-adherent group manifested significantly higher PTD (<28 weeks; 16.7% vs. 4.4%, p = 0.04, <34 weeks; 23.8% vs. 5.8%, p = 0.006) and neonatal composite morbidity (20.5% vs. 5.9%, p = 0.028) rates than the adherent-to-guideline group despite similar perioperative variables and lower PTD history rates. The non-adherent group with CL ≥ 2 cm at the time of cerclage was also associated with severe histologic chorioamnionitis (p = 0.033)., Conclusion: Cerclage performed beyond the current guidelines in pregnant women with CL ≥ 2.0 cm may confer an additional risk of perinatal complications in association with severe placental inflammation., Competing Interests: Declaration of competing interest The authors of this publication disclose that there are no relevant financial, personal, political, intellectual, or religious interests to declare., (Copyright © 2021. Published by Elsevier B.V.)

The rate of maternal deaths in remote areas in eastern Indonesia-where geographic conditions are difficult and the standard of infrastructure is poor-is high. Long travel times needed to reach emergency obstetric care (EMOC) is one cause of maternal death. District governments in eastern Indonesia need effective planning to improve access to EMOC. The aim of this study was to develop a scenario modelling tool to be used in planning to improve access to EMOC in eastern Indonesia. The scenario model was developed using the geographic information system tool in NetLogo. This model has two inputs: the location of the EMOC facility (PONED) and the travel cost of moving across geographical features in the rainy and dry seasons. We added a cost-benefit analysis to the model: cost is the budget for building the infrastructure; benefit is the number of people who can travel to the EMOC in less than 1 hour if the planned infrastructure is built. We introduced the tool to representative midwives from all districts of Nusa Tenggara Timur province and to staff of Kupang district planning agency. We found that the tool can model accessibility to EMOC based on weather conditions; compare alternative infrastructure planning scenarios based on cost-benefit analysis; enable users to identify and mark poor infrastructure; and model travel across the ocean. Lay people can easily use the tool through interactive scenario modelling: midwives can use it for evidence to support planning proposals to improve access to EMOC in their district; district planning agencies can use it to choose the best plan to improve access to EMOC. Scenario modelling has potential for use in evidence-based planning to improve access to EMOC in low-income and lower-middle-income countries with poor infrastructure, difficult geography conditions, limited budgets and lack of trained personnel., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Variable and inadequate quality of maternity care is a critical factor in persistently high rates of maternal and neonatal mortality in Uganda. We investigated whether provider quality of care deviates from knowledge and the factors associated with these 'know-do gaps' in Ugandan maternity facilities., Methods: Data were collected from 109 providers in 40 facilities. Quality was measured using direct observations of intrapartum care, and scores were based on the percentage of essential care actions provided out of a 20-item validated quality index. Knowledge was measured based on the percentage of items that providers reported knowing to do using vignette surveys. The know-do gap was the difference between knowledge and quality. Multivariable models were used to assess the association between provider- and facility-level characteristics and knowledge, quality and know-do gaps., Results: The average quality score was 45%, with quality varying widely within and across providers. The mean knowledge score was 70%, yielding a mean know-do gap of 25%. Know-do gaps were largest for practices related to infection control, vitals monitoring, and prevention of postpartum haemorrhage. The association between quality and knowledge scores was positive but small (P = 0.08), so know-do gaps were largest for providers with the highest knowledge scores. Greater provider training was positively associated with knowledge (P = 0.005) but not with quality (P = 0.60). Having 10 or more years of work experience was associated with higher quality scores (5.3, 95%CI: 0.6 to 10.1), while higher patient volumes were associated with lower quality scores (-2.2, 95%CI: -3.7 to - 0.07). None of the factors of provider motivation, cadre, availability of essential medicines and supplies or facility staffing were associated with quality or know-do gaps., Conclusions: Our results indicate that, in Uganda, gaps between knowledge and quality do not appear to be explained by factors such as lack of motivation, education, training or supplies. Gaps are particularly large for essential practices related to prevention of postpartum haemorrhage, a leading cause of maternal mortality in Uganda and similar settings., (© 2021 John Wiley & Sons Ltd.)

Third trimester ultrasound has long been in obstetrics a topic of debate. This issue is framed in a historical debate on the effectiveness of routine obstetrical ultrasound and two opposing trends originated in America and Europe, respectively. Primary function of this ultrasound has been to detect fetal growth restriction, but no study has shown evidence of improving perinatal outcomes. Other secondary functions are detection of fetal abnormalities or evaluation of fetal presentation, and they have also shown no evidence. Despite the continuous appearance of works in this regard, health policies of both american and european trends have not been modified. Future seems to show a prolongation of the stalemate. Those health systems with a universal third trimester policy should propose an optimization of the test, in order to improve the benefits and obtain data for future studies that could resolve this longstanding debate., Competing Interests: Declaration of competing interest The authors report no conflict of interest., (Copyright © 2021. Published by Elsevier B.V.)

Introduction: emergency obstetric care (EmOC) is a high-impact priority intervention strongly recommended for improving maternal health outcomes. The objectives of this study were to assess the availability, utilization, and quality of emergency obstetric care services in the Governorate of Sousse (Tunisia)., Methods: a cross-sectional study was conducted among public health facilities which performed deliveries in Sousse in 2017. Data were collected by consulting clinical records and registers and interviewing staff using WHO EmOC tools. Emergency obstetric care (EmOC) indicators were calculated., Results: only the University maternity Unit functioned as full comprehensive EmOC facility. No other public facility provided all the 7 Basic EmOC signal functions 3 months prior to the survey. The unperformed signal functions were: administration of parenteral antibiotics, manual removal of placenta and assisted vaginal delivery. The number of EmOC facilities was 0.72 per 500,000 inhabitants. The met need for EmOC was 89.5%. The proportion of caesarean section was 24.2%. The direct obstetric case fatality rate was 0.159% and intrapartum and very early neonatal death rate was 0.65%., Conclusion: raising maternity facilities to a minimum level of basic EmOC status would be a major contributing step towards maternal mortality reduction., Competing Interests: The authors declare no competing interests., (Copyright: Manel Limam et al.)

Background: We aim to assess competencies (knowledge, skills and attitudes) of midwifery care providers as well as their experiences and perceptions of in-service training in the four study countries; Benin, Malawi, Tanzania and Uganda as part of the Action Leveraging Evidence to Reduce perinatal mortality and morbidity in sub-Saharan Africa project (ALERT). While today more women in low- and middle-income countries give birth in health care facilities, reductions in maternal and neonatal mortality have been less than expected. This paradox may be explained by the standard and quality of intrapartum care provision which depends on several factors such as health workforce capacity and the readiness of the health system as well as access to care., Methods: Using an explanatory sequential mixed method design we will employ three methods (i) a survey will be conducted using self-administered questionnaires assessing knowledge, (ii) skills drills assessing basic intrapartum skills and attitudes, using an observation checklist and (iii) Focus Group Discussions (FGDs) to explore midwifery care providers' experiences and perceptions of in-service training. All midwifery care providers in the study facilities are eligible to participate in the study. For the skills drills a stratified sample of midwifery care providers will be selected in each hospital according to the number of providers and, professional titles and purposive sampling will be used for the FGDs. Descriptive summary statistics from the survey and skills drills will be presented by country. Conventional content analysis will be employed for data analysis of the FGDs., Discussion: We envision comparative insight across hospitals and countries. The findings will be used to inform a targeted quality in-service training and quality improvement intervention related to provision of basic intrapartum care as part of the ALERT project., Trial Registration: PACTR202006793783148-June 17th, 2020.

Member States at this year's World Health Assembly 73 (WHA73), held virtually for the first time due to the COVID-19 pandemic, passed multiple resolutions that must be considered when framing efforts to strengthen surgical systems. Surgery has been a relatively neglected field in the global health landscape due to its nature as a cross-cutting treatment rather than focusing on a specific disease or demographic. However, in recent years, access to essential and emergency surgical, obstetric, and anesthesia care has gained increasing recognition as a vital aspect of global health. The WHA73 Resolutions concern specific conditions, as has been characteristic of global health practice, yet proper care for each highlighted disease is inextricably linked to surgical care. Global surgery advocates must recognize how surgical system strengthening aligns with these strategic priorities in order to ensure that surgical care continues to be integrated into efforts to decrease global health disparities., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Having to cope with corona virus disease 2019 (COVID-19) is likely to create imbalances in health care provision in the obstetrics and gynecology practices in Africa where most countries still battle with high rate of maternal morbidities and mortalities as well as poor or inadequate quality gynecological care. COVID-19 has spread to the continents of the world including all African nations since it was first reported in Wuhan, China in December 2019. Its impact and implications on the obstetrics and gynecology practice in Africa are yet to be fully explored. Routine essential services are being disrupted; therefore, giving rise to the need to redeploy the already limited health personnel across health services in Africa. This is an attempt to discuss the potential implications for obstetrics and gynecologic practice in Africa., Competing Interests: The authors declare no competing interests., (Copyright: Timothy Abiola Olusesan Oluwasola et al.)

Background: With increasing cases of iatrogenic premature ovarian insufficiency (POI), more clinicians are required to counsel patients regarding the gonadotoxic effects of iatrogenic treatments. This survey aimed to explore obstetricians and gynaecologists' knowledge regarding iatrogenic POI. A national online questionnaire survey was conducted across China. Respondents were asked to select the iatrogenic condition(s) that can cause POI based on their experience and knowledge., Results: Of the 5523 returned questionnaires, 4995 were analysed. Among tumour therapies causing POI, most respondents agreed that radiotherapy (73.5% of respondents) and chemotherapy (64.1%) are risk factors for POI. While only 6.5 and 7.8% of the gynaecological oncologists believed that tumour immunotherapy and tumour-targeting therapy, respectively, may cause ovarian impairment, 31.8 and 22.2% of the non-gynaecologic oncologists believed that these therapies could affect ovarian health. Most respondents believed that ovarian cystectomy (54.4%) was a risk factor for POI. In contrast, only a few respondents believed that hysterectomy with bilateral salpingectomy (39.6%) and uterine artery embolisation (33.5%) could cause ovarian impairment. Only 30.5% of respondents believed that immunosuppressants (ISs) increased the risk of POI. Views differed with experience and hospital setting., Conclusions: The knowledge of gonadal toxicity due to traditional tumour treatments is generally high among Chinese obstetricians and gynaecologists. A misunderstanding may exist in primary care hospitals and general gynaecologists regarding a link between novel tumour treatments and POI, owing to the lack of convincing evidence. Knowledge of POI caused by hysterectomy and ISs should be improved.

Background: An increase in the uptake of skilled birth attendance is expected to reduce maternal mortality in low- and middle-income countries. In Tanzania, the proportion of deliveries assisted by a skilled birth attendant is only 64% and the maternal mortality ratio is still 398/100.000 live births. This article explores different aspects of quality of care and respectful care in relation to maternal healthcare. It then examines the influence of these aspects of care on the uptake of skilled birth attendance in Tanzania in order to offer recommendations on how to increase the skilled birth attendance rate., Methods: This narrative review employed the "person-centered care framework for reproductive health equity" as outlined by Sudhinaraset (2017). Academic databases, search engines and websites were consulted, and snowball sampling was used. Full-text English articles from the last 10 years were included., Results: Uptake of skilled birth attendance was influenced by different aspects of technical quality of maternal care as well as person-centred care, and these factors were interrelated. For example, disrespectful care was linked to factors which made the working circumstances of healthcare providers more difficult such as resource shortages, low levels of integrated care, inadequate referral systems, and bad management. These issues disproportionately affected rural facilities. However, disrespectful care could sometimes be attributed to personal attitudes and discrimination on the part of healthcare providers. Dissatisfied patients responded with either quiet acceptance of the circumstances, by delivering at home with a traditional birth attendant, or bypassing to other facilities. Best practices to increase respectful care show that multi-component interventions are needed on birth preparedness, attitude and infrastructure improvement, and birth companionship, with strong management and accountability at all levels., Conclusions: To further increase the uptake of skilled birth attendance, respectful care needs to be addressed within strategic plans. Multi-component interventions are required, with multi-stakeholder involvement. Participation of traditional birth attendants in counselling and referral can be considered. Future advances in information and communication technology might support improved quality of care.

The spread of COVID-19 has resulted in a high risk of infection in hospitals worldwide. The medical staff in emergency rooms, in particular, have borne the brunt of the pandemic, and strict protection measures are needed to avoid infection in these units. Taiwan as a whole has performed extremely well in this epidemic, an achievement that has been acknowledged internationally. This success can be attributed to the Taiwan Epidemic Prevention Management Center's extensive experience and courageous strategy. The emergency department professionals of all hospitals, in conjunction with the outstanding performance of the center's policy, have also done much to control the infection's spread. However, excessive protection can also negatively affect patients' safety and the quality of medical care, especially for pregnant and parturient women. This article uses two actual cases from a medical center in northern Taiwan to discuss the impact of COVID-19 on pregnant women. This case study serves to highlight that, to ensure more effective coordination during severe epidemics, a comprehensive infection prevention plan should be formulated. In addition, pregnant women's human rights must be safeguarded so that various protective mechanisms can be effectively used to achieve win-win solutions. Hospitals need to plan their production methods and timing in advance for when pregnant patients are in critical condition. The findings include that obstetricians recommend caesarean sections as a safer method in during epidemics. Emergency room physicians and obstetricians should also actively assist mothers prepare for birth to enhance maternal and fetal safety., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article., (Copyright © 2020. Published by Elsevier B.V.)

Background: The period around childbirth and the first 24 hours postpartum remains a perilous time for both mother and newborn. Health care providers' compliance to the World Health Organization modified partogram across the active first stage of labor is a graphic representation of a mother's condition that is used as a guide in providing quality obstetrics care. However, little evidence is documented on the health providers' adherence to the use of the partograph in Ethiopia, which limits health care providers' ability to improve quality care services. Therefore, this study assessed the adherence of partograph use and associated factors in Ethiopia., Methods: Data from the Ethiopian 2016 National Emergency Obstetric and Newborn Care survey of 3,804 health facilities that provided maternity services were used. We extracted 2611 partograph charts over a 12 months period prior to the survey to review the proper recording of each component. Data analyses were performed using SPSS version 22.0 software. A logistic regression analyses was used to identify the association of explanatory variables with the outcome variable. A p-value of <0.05 was considered as cut off point to declare the significance association in the multivariable analysis., Results: Of the total 2611 partographs reviewed, 561(21.5%) of them were fully recorded as per the WHO guideline. Particularly, molding in 50%, color of liquor in 70.5%, fetal heart beat in 93.3%, cervical dilation in 89.6%, descent in 63.2%, uterine contraction in 94.5%, blood pressure in 80.5%, pulse rate in 70.5%, and temperature in 53% were accurately recorded. The odds of adherence to partograph use were 1.4 in rural health facilities when compared to their counterparts (AOR=1.44; 95% CI: 1.15, 1.80, P- 0.002)., Conclusion: This study revealed a poor level of adherence in partograph use in Ethiopia. Molding, maternal temperature and decent were the least recorded parameters of the partograph. The odds of completion of partograph were high in rural facilities. Strong supporting supervision and mentoring the health workers to better record and use of partograph are needed mainly in urban health facilities. Moreover in the future, interventional research should be conducted to improve the current rate of adherence.

Background: The management of pregnant women with sickle cell disease (SCD) poses a major challenge for maternal healthcare services owing to the potential for complications associated with morbidity and mortality. Trustworthy evidence-based clinical practice guidelines (CPGs) have a major impact on the positive outcomes of appropriate healthcare. The objective of this study was to critically appraise the quality of recent CPGs for SCD in pregnant women., Methods: Clinical questions were identified and the relevant CPG and bibliographic databases were searched and screened for eligible CPGs. Each CPG was appraised by four independent appraisers using the AGREE II Instrument. Inter-rater analysis was conducted., Results: Four eligible CPGs were appraised: American College of Obstetricians and Gynecologists (ACOG), National Heart, Lung, and Blood Institute (NHLBI), National Institute of Health and Care Excellence (NICE), and Royal College of Obstetricians and Gynaecologists (RCOG). Among them, the overall assessments of three CPGs (NICE, RCOG, NHLBI) scored greater than 70%; these findings were consistent with the high scores in the six domains of AGREE II, including:[1] scope and purpose,[2] stakeholder involvement,[3] rigor of development,[4] clarity of presentation,[5] applicability, and [6] editorial independence domains. Domain [3] scored (90%, 73%, 71%), domain [5] (90%, 46%, 47%), and domain [6] (71%, 77%, 52%) for NICE, RCOG, and NHLBI, respectively. Overall, the clinical recommendations were not significantly different between the included CPGs., Conclusions: Three evidence-based CPGs presented superior methodological quality. NICE demonstrated the highest quality followed by RCOG and NHLBI and all three CPGs were recommended for use in practice.

Aims/introduction: This study aimed to investigate the effects of the introduction of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for diagnosing gestational diabetes mellitus (GDM) on maternal and neonatal outcomes in Japan., Materials and Methods: This was a retrospective study carried out at a tertiary center in Japan. Previously in Japan, GDM was diagnosed if two or more of the following Japan Society of Obstetrics and Gynecology (JSOG) criteria were met: fasting plasma glucose ≥100 mg/dL, 1-h value ≥180 mg/dL or 2-h value ≥150 mg/dL on the 75-g oral glucose tolerance. Since 2010, GDM has been diagnosed if one or more of the following IADPSG criteria are met: fasting plasma glucose ≥92 mg/dL, 1-h value ≥180 mg/dL or 2-h value ≥153 mg/dL on the 75-g oral glucose tolerance. We compared the pregnancy outcomes of all pregnant women with singleton pregnancies after 22 weeks' gestation at our hospital before (JSOG period) and after (IADPSG period) the IADPSG criteria were adopted., Results: There were 3,912 women in the JSOG period and 4,772 in the IADPSG period. GDM prevalence increased from 2.9% in the JSOG period to 13% in the IADPSG period (P < 0.001). No significant differences between the groups were found in rates of macrosomia, or large for gestational age, and no significant differences were found in birthweight. The neonatal hypoglycemia rate and neonatal intensive care unit admission rate were significantly lower in the IADPSG period (adjusted odds ratio 0.51 and 0.78, respectively)., Conclusions: Introduction of the IADPSG criteria for diagnosing GDM increased GDM diagnosis frequency fourfold, but reduced neonatal intensive care unit admission and neonatal hypoglycemia rates significantly., (© 2020 The Authors. Journal of Diabetes Investigation published by Asian Association for the Study of Diabetes (AASD) and John Wiley & Sons Australia, Ltd.)

Background: Hand Hygiene (HH) has been described as the cornerstone and starting point in all infection control. Compliance to HH is a fundamental quality indicator. The aim of this study was to investigate the HH compliance among Health-care Workers (HCWs) in Benin surgical care units., Methods: A multicenter prospective observational study was conducted for two months. The World Health Organization (WHO) Hand Hygiene Observation Tool was used in obstetric and gastrointestinal surgery through six public hospitals in Benin. HH compliance was calculated by dividing the number of times HH was performed by the total number of opportunities. HH technique and duration were also observed., Results: A total of 1315 HH opportunities were identified during observation period. Overall, the compliance rate was 33.3% (438/1315), without significant difference between professional categories (nurses =34.2%; auxiliaries =32.7%; and physicians =32.4%; p = 0.705). However, compliance rates differed (p < 0.001) between obstetric (49.4%) and gastrointestinal surgery (24.3%). Generally, HCWs were more compliant after body fluid exposure (54.5%) and after touching patient (37.5%), but less before patient contact (25.9%) and after touching patient surroundings (29.1%). HCWs were more likely to use soap and water (72.1%) compared to the alcohol based hand rub solution (27.9%). For all of the WHO five moments, hand washing was the most preferred action. For instance, hand rub only was observed 3.9% after body fluid exposure and 16.3% before aseptic action compared to hand washing at 50.6 and 16.7% respectively. Duration of HH performance was not correctly adhered to 94% of alcohol hand rub cases (mean duration 9 ± 6 s instead of 20 to 30 s) and 99.5% of hand washing cases (10 ± 7 s instead of the recommended 40 to 60 s). Of the 432 HCWs observed, 77.3% followed HH prerequisites (i.e. no artificial fingernails, no jewellery). We also noted a lack of permanent hand hygiene infrastructures such as sink, soap, towels and clean water., Conclusion: Compliance in surgery was found to be low in Benin hospitals. They missed two opportunities out of three to apply HH and when HH was applied, technique and duration were not appropriate. HH practices should be a priority to improve patient safety in Benin.

Background: Poor quality obstetric and newborn care persists in sub-Saharan Africa and weak provider competence is an important contributor. To be competent, providers need to be both knowledgeable and confident in their ability to perform necessary clinical actions. Confidence or self-efficacy has not been extensively studied but may be related to individuals' knowledge, ability to practice their skills, and other modifiable factors. In this study, we investigated how knowledge and scope of practice are associated with provider confidence in delivering obstetric and newborn health services in Uganda and Zambia., Methods: This study was a secondary analysis of data from an obstetric and newborn care program implementation evaluation. Provider knowledge, scope of practice (completion of a series of obstetric tasks in the past 3 months) and confidence in delivering obstetric and newborn care were measured post intervention in intervention and comparison districts in Uganda and Zambia. We used multiple linear regression models to investigate the extent to which exposure to a wider range of clinical tasks associated with confidence, adjusting for facility and provider characteristics., Results: Of the 574 providers included in the study, 69% were female, 24% were nurses, and 6% were doctors. The mean confidence score was 71%. Providers' mean knowledge score was 56% and they reported performing 57% of basic obstetric tasks in the past 3 months. In the adjusted model, providers who completed more than 69% of the obstetric tasks reported a 13-percentage point (95% CI 0.08, 0.17) higher confidence than providers who performed less than 50% of the tasks. Female providers and nurses were considerably less confident than males and doctors. Provider knowledge was moderately associated with provider confidence., Conclusions: Our study showed that scope of practice (the range of clinical tasks routinely performed by providers) is an important determinant of confidence. Ensuring that providers are exposed to a variety of services is crucial to support improvement in provider confidence and competence. Policies to improve provider confidence and pre-service training should also address differences by gender and by cadres.

Justification: During the current rapidly evolving pandemic of COVID-19 infection, pregnant women with suspected or confirmed COVID-19 and their newborn infants form a special vulnerable group that needs immediate attention. Unlike other elective medical and surgical problems for which care can be deferred during the pandemic, pregnancies and childbirths continue. Perinatal period poses unique challenges and care of the mother-baby dyads requires special resources for prevention of transmission, diagnosis of infection and providing clinical care during labor, resuscitation and postnatal period., Process: The GRADE approach recommended by the World Health Organization was used to develop the guideline. A Guideline Development Group (GDG) comprising of obstetricians, neonatologists and pediatricians was constituted. The GDG drafted a list of questions which are likely to be faced by clinicians involved in obstetric and neonatal care. An e-survey was carried out amongst a wider group of clinicians to invite more questions and prioritize. Literature search was carried out in PubMed and websites of relevant international and national professional organizations. Existing guidelines, systematic reviews, clinical trials, narrative reviews and other descriptive reports were reviewed. For the practice questions, the evidence was extracted into evidence profiles. The context, resources required, values and preferences were considered for developing the recommendations., Objectives: To provide recommendations for prevention of transmission, diagnosis of infection and providing clinical care during labor, resuscitation and postnatal period., Recommendations: A set of twenty recommendations are provided under the following broad headings: 1) pregnant women with travel history, clinical suspicion or confirmed COVID-19 infection; 2) neonatal care; 3) prevention and infection control; 4) diagnosis; 5) general questions.

Background: Efforts to expand access to institutional delivery alone without quality of care do not guarantee better survival. However, little evidence documents the quality of childbirth care in Ethiopia, which limits our ability to improve quality. Therefore, this study assessed the quality of and barriers to routine childbirth care signal functions during intra-partum and immediate postpartum period., Methods: A sequential explanatory mixed method study was conducted among 225 skilled birth attendants who attended 876 recently delivered women in primary level facilities. A multi stage sampling procedure was used for the quantitative phase whilst purposive sampling was used for the qualitative phase. The quantitative survey recruitment occurred in July to August 2018 and in April 2019 for the qualitative key informant interview and Focus Group Discussions (FGD). A validated quantitative tool from a previous validated measurement study was used to collect quantitative data, whereas an interview guide, informed by the literature and quantitative findings, was used to collect the qualitative data. Principal component analysis and a series of univariate and multivariate linear regression analysis were used to analyze the quantitative data. For the qualitative data, verbatim review of the data was iteratively followed by content analysis and triangulation with the quantitative results., Results: This study showed that one out of five (20.7%, n = 181) mothers received high quality of care in primary level facilities. Primary hospitals (β = 1.27, 95% CI:0.80,1.84, p = 0.001), facilities which had staff rotation policies (β = 2.19, 95% CI:0.01,4.31, p = 0.019), maternal involvement in care decisions (β = 0.92, 95% CI:0.38,1.47, p = 0.001), facilities with maternal and newborn health quality improvement initiatives (β = 1.58, 95% CI:0.26, 3.43, p = 0.001), compassionate respectful maternity care training (β = 0.08, 95% CI: 0.07,0.88, p = 0.021), client flow for delivery (β = 0.19, 95% CI:-0.34, -0.04, p = 0.012), mentorship (β = 0.02, 95% CI:0.01, 0.78, p = 0.049), and providers' satisfaction (β = 0.16, 95% CI:0.03, 0.29, p = 0.013) were predictors of quality of care. This is complemented by qualitative research findings that poor quality of care during delivery and immediate postpartum related to: work related burnout, gap between providers' skill and knowledge, lack of enabling working environment, poor motivation scheme and issues related to retention, poor providers caring behavior, unable translate training into practice, mismatch between number of provider and facility client flow for delivery, and in availability of essential medicine and supplies., Conclusions: There is poor quality of childbirth care in primary level facilities of Tigray. Primary hospitals, facilities with staff rotation, maternal and newborn health quality improvement initiatives, maternal involvement in care decisions, training on compassionate respectful maternity care, mentorship, and high provider satisfaction were found to have significantly increased quality of care. However, client flow for delivery service is negatively associated with quality of care. Efforts must be made to improve the quality of care through catchment-based mentorship to increase providers' level of adherence to good practices and standards. More attention and thoughtful strategies are required to minimize providers' work-related burnout., Competing Interests: The authors have declared that no competing interests exist.

Background: Ghana significantly reduced maternal and newborn mortality between 1990 and 2015, largely through efforts focused on improving access to care. Yet achieving further progress requires improving the quality and timeliness of care. Beginning in 2013, Ghana Health Service and Kybele, a US-based non-governmental organization, developed an innovative obstetric triage system to help midwives assess, diagnosis, and determine appropriate care plans more quickly and accurately. In 2019, efforts began to scale this successful intervention into six additional hospitals. This protocol describes the theory-based implementation approach guiding scale-up and presents the proposed mixed-methods evaluation plan., Methods: An implementation theory was developed to describe how complementary implementation strategies would be bundled into a multi-level implementation approach. Drawing on the Interactive Systems Framework and Evidenced Based System for Implementation Support, the proposed implementation approach is designed to help individual facilities develop implementation capacity and also build a learning network across facilities to support the implementation of evidence-based interventions. A convergent design mixed methods approach will be used to evaluate implementation with relevant data drawn from tailored assessments, routinely collected process and quality monitoring data, textual analysis of relevant documents and WhatsApp group messages, and key informant interviews. Implementation outcomes of interest are acceptability, adoption, and sustainability., Discussion: The past decade has seen a rapid growth in the development of frameworks, models, and theories of implementation, yet there remains little guidance on how to use these to operationalize implementation practice. This study proposes one method for using implementation theory, paired with other kinds of mid-level and program theory, to guide the replication and evaluation of a clinical intervention in a complex, real-world setting. The results of this study should help to provide evidence of how implementation theory can be used to help close the "know-do" gap. Every woman and every newborn deserves a safe and positive birth experience. Yet in many parts of the world, this goal is often more aspiration than reality. In 2006, Kybele, a US-based non-governmental organization, began working with the Ghanaian government to improve the quality of obstetric and newborn care in a large hospital in Greater Accra. One successful program was the development of a triage system that would help midwives rapidly assess pregnant women to determine who needed what kind of care and develop risk-based care plans. The program was then replicated in another large hospital in the Greater Accra region, where a systematic theory to inform triage implementation was developed. This paper describes the extension of this approach to scale-up the triage program implementation in six additional hospitals. The scale-up is guided by a multi-level theory that extends the facility level theory to include cross-facility learning networks and oversight by the health system. We explain the process of theory development to implement interventions and demonstrate how these require the combination of local contextual knowledge with evidence from the implementation science literature. We also describe our approach for evaluating the theory to assess its effectiveness in achieving key implementation outcomes. This paper provides an example of how to use implementation theories to guide the development and evaluation of complex programs in real-world settings.

Obstetrics has unique considerations for high stakes and dynamic clinical care of ≥2 patients. Obstetric crisis situations require efficient and coordinated responses from the entire multidisciplinary team. Actions that teams perform, or omit, can strongly impact peripartum and perinatal outcomes. Cognitive aids are tools that aim to improve patient safety, efficiency in health care management, and patient outcomes. However, they are intended to be combined with clinician judgment and training, not as absolute or exhaustive standards of care for patient management. There is simulation-based evidence showing efficacy of cognitive aids for enhancing appropriate team management during crises, especially with a reader role, with growing literature supporting use in obstetric and nonobstetric clinical settings when combined with local customization and implementation efforts. The purpose of this article is to summarize current understanding and available resources for cognitive aid design, implementation, and use in obstetrics and to highlight existing gaps that can stimulate further enhancement in this field.

Introduction: Optimising the safety of obstetric patient care is a primary concern for many hospitals. Performance indicators measuring aspects of patient care processes can lead to improvements in health systems and the prevention of harm to the patient. We present our protocol for a scoping review to identify indicators for obstetric safety in low risk births. We aim to identify indicators addressing preventable hospital harms, to summarise the data and synthesise results., Methods and Analysis: We will use methods described by Arksey and O'Malley and further expanded by Levac et al . We will search electronic databases such as Medline, Embase, CINAHL and the Cochrane Library, and websites from professional bodies and other organisations, using an iterative search strategy.Two reviewers will independently screen titles and abstracts of search results to determine eligibility for inclusion. If eligibility is not clear, the reviewers will screen the full text version. If reviewers' decisions regarding eligibility differ, a third reviewer will review the record. Two reviewers will independently extract data from records that meet our inclusion criteria using a standardised data collection form. We will narratively describe quantitative data, such as the frequency with which indicators are identified, and conduct a thematic analysis of the qualitative data. We will compile a comprehensive list of patient safety indicators and organise them according to concepts that best suit the data such as the Donabedian model or the Hospital Harm Framework. We will discuss the implications for future research, clinical practice and policy-making. We will report the conduct of the review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews checklist., Ethics and Dissemination: The sources of information included in this scoping review will be available to the public. Therefore, ethics approval is not warranted. We will disseminate results in a peer-reviewed publication, conference/event presentation(s) and stakeholder communications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe some characteristics of the 97 teaching hospitals participating in the Projeto de Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia (Apice ON-Project for Improvement and Innovation in Care and Teaching in Obstetrics and Neonatology)., Methods: The semester prior to the beginning of the program was adopted as the baseline to evaluate the subsequent structural and processes changes of this project. Secondary data from the first half of 2017 were extracted from the National Registry of Health Establishments (NRHE), the Hospital Information System and the Sistema de Informações sobre Nascidos Vivos (SINASC-Live Birth Information System)., Results: Before the implementation of the project, only 66% of the hospitals had a Baby-friendly Hospital Initiative, only 3% offered special accommodations for high-risk pregnant women, mothers and their newborns, and 45.4% hospitals adopted the skin-to-skin contact; 97% hospitals had separate rooms for pre-labor and vaginal delivery (93%), not following the recommendations of the Ministry of Health; nine hospitals (9%) had no rooming-in; there were few obstetrics nurses (less than 1% of professionals enrolled in the NRHE), and in only six hospitals the proportion of births assisted by this professional was above 50% of vaginal deliveries, while in eight this percentage ranged between 15% and 50%; the average cesarean section rate was 42%, ranging between 37.6% (Southeast) and 49.1% (Northeast); ten hospitals did not charge for companions according to inpatient hospital authorization., Conclusion: The study strengthens the relevance of the Apice ON project as an inducer of change of the care model in teaching hospitals and, therefore, as a strategy for the implementation of the national public policy represented by the Stork Network.

The recommendations present the current knowledge and procedures, which can be modified and changed in some cases, after careful analysis of a given clinical situation, which in the future may become the basis for their modification and updating.

Polish Society of Gynecologists and Obstetricians recommendations on supplementation during pregnancy.

Periostin (POSTN) is a multifunctional glycoprotein that belongs to the group of extracellular matrix (ECM) proteins. Due to the molecular structure, cellular interactions, tissue locations as well functions of POSTN, we realize that its pivotal role is organization and regulation of ECM microenvironment. In available databases there is a lack of data summarizing current knowledge about POSTN expression in the field of gynecology and obstetrics. We conducted a search in PubMed of the National Library of Medicine and Google Scholar. Databases were extensively searched for all original and review articles/book chapters published in English until December 2019 and related to periostin expression. All relevant articles were reviewed and presented as appropriate. In the field of POSTN expression there is only one paper evaluating its involvement in cervical cancer cell metabolism and only two studies analyzing its myometrial commitment: maintenance during pregnancy and induction of parturition in physiology as well control of fibroids biology in pathology. Much more attention has been devoted to the expression of described protein in the endometriosis, and above all in ovarian cancer. Finally, a few studies carried out among pregnant women were presented. In this review study we presented current knowledge about periostin expression in the field of gynecology and obstetrics. Many achieved results are interesting and further studies are needed to verify some hypotheses. Structure, signaling pathways as well many functions of periostin are well-described. However, as it was clearly shown there is a lot of unknown issues which are waiting to be explored.

This study was performed to investigate whether the Japanese guidelines for gestational weight gain (GWG) can be used to determine the risks of multiple pregnancy outcomes and estimate optimal GWG in 101,336 women with singleton pregnancies in 2013. Multivariable logistic regression analyses indicated that the risks associated with low birth weight, small for gestational age, and preterm birth increased significantly with weight gain below the Japanese guidelines, and the risks of macrosomia and large for gestational age increased with weight gain above the guidelines regardless of Asian-specific pre-pregnancy body mass index (BMI). The GWG cutoff points estimated from the adjusted area under the receiver operating characteristics curve >0.6 corresponded to 10-13.8 kg in underweight women with pre-pregnancy BMI < 18.5 kg/m 2 ; 10-13.7 kg in normal weight women with pre-pregnancy BMI 18.5-22.9 kg/m 2 ; 8.5-11.4 kg in overweight women with pre-pregnancy BMI 23-24.9 kg/m 2 , 5-13.3 kg in obese women with pre-pregnancy BMI 25-29.9 kg/m 2 ; and 4.7 kg in obese women with pre-pregnancy BMI ≥ 30 kg/m 2 . The optimal GWG ranges proposed by the present study are slightly higher than those recommended by the current Japanese guidelines.

Background: Preterm infants are a group at high risk of having experienced placental insufficiency. It is unclear which growth charts perform best in identifying infants at increased risk of stillbirth and other adverse perinatal outcomes. We compared 2 birthweight charts (population centiles and INTERGROWTH-21st birthweight centiles) and 3 fetal growth charts (INTERGROWTH-21st fetal growth charts, World Health Organization fetal growth charts, and Gestation Related Optimal Weight [GROW] customised growth charts) to identify which chart performed best in identifying infants at increased risk of adverse perinatal outcome in a preterm population., Methods and Findings: We conducted a retrospective cohort study of all preterm infants born at 24.0 to 36.9 weeks gestation in Victoria, Australia, from 2005 to 2015 (28,968 records available for analysis). All above growth charts were applied to the population. Proportions classified as <5th centile and <10th centile by each chart were compared, as were proportions of stillborn infants considered small for gestational age (SGA, <10th centile) by each chart. We then compared the relative performance of non-overlapping SGA cohorts by each chart to our low-risk reference population (infants born appropriate size for gestational age [>10th and <90th centile] by all intrauterine charts [AGAall]) for the following perinatal outcomes: stillbirth, perinatal mortality (stillbirth or neonatal death), Apgar <4 or <7 at 5 minutes, neonatal intensive care unit admissions, suspicion of poor fetal growth leading to expedited delivery, and cesarean section. All intrauterine charts classified a greater proportion of infants as <5th or <10th centile than birthweight charts. The magnitude of the difference between birthweight and fetal charts was greater at more preterm gestations. Of the fetal charts, GROW customised charts classified the greatest number of infants as SGA (22.3%) and the greatest number of stillborn infants as SGA (57%). INTERGROWTH classified almost no additional infants as SGA that were not already considered SGA on GROW or WHO charts; however, those infants classified as SGA by INTERGROWTH had the greatest risk of both stillbirth and total perinatal mortality. GROW customised charts classified a larger proportion of infants as SGA, and these infants were still at increased risk of mortality and adverse perinatal outcomes compared to the AGAall population. Consistent with similar studies in this field, our study was limited in comparing growth charts by the degree of overlap, with many infants classified as SGA by multiple charts. We attempted to overcome this by examining and comparing sub-populations classified as SGA by only 1 growth chart., Conclusions: In this study, fetal charts classified greater proportions of preterm and stillborn infants as SGA, which more accurately reflected true fetal growth restriction. Of the intrauterine charts, INTERGROWTH classified the smallest number of preterm infants as SGA, although it identified a particularly high-risk cohort, and GROW customised charts classified the greatest number at increased risk of perinatal mortality., Competing Interests: The authors have declared that no competing interests exist.

Objective: To assess the completeness of obstetric referral letters/notes at the district level of healthcare., Design: An implementation research within three districts in Greater Accra region using mixed methods. During baseline and intervention phases, referral processes for all obstetric referrals from lower level facilities seen at the district hospitals were documented including indications for referrals, availability and completeness of referral notes/forms. An assessment of before and after intervention availability and completeness of referral forms was carried out. Focus group discussions, non-participant observations and in-depth interviews with health workers and pregnant women were conducted for qualitative data., Setting: Three (3) districts in the Greater Accra region of Ghana., Participants: Pregnant women referred from lower levels of care to and seen at the district hospital, health workers within the three districts and pregnant women attending antenatal clinic in the district and their family members or spouses., Intervention: An enhanced interfacility referral communication system consisting of training, provision of communication tools for facilities, formation of hospital referral teams and strengthening feedback mechanisms., Outcome: Completeness of obstetric referral letters/notes., Results: Proportion of obstetric referrals with referral notes improved from 27.2% to 44.3% from the baseline to intervention period. Mean completeness (95% CI) of all forms was 71.3% (64.1% to 78.5%) for the study period, improving from 70.7% (60.4% to 80.9%) to 71.9% (61.1% to 82.7%) from baseline to intervention periods. Health workers reported they do not always provide referral notes and that most referral notes are not completely filled due to various reasons., Conclusions: Most obstetric referrals did not have referral notes. The few notes provided were not completely filled. Interventions such as training of health workers, regular review of referral processes and use of electronic records can help improve both the provision of and completeness of the referral notes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Maternal mental health is an international public health concern. Many women experience mental ill-health during and after pregnancy, but assessment is not part of routine maternity care in many low- and middle-income countries. Healthcare providers are in a position to identify and support women who experience mental health disorders during and after pregnancy. We sought to investigate the knowledge, attitudes and perceptions of routine screening for maternal mental health during and after pregnancy among healthcare providers providing routine maternity care in Accra, Ghana. Enabling factors, barriers and potential management options to routinely screen maternal mental health during and after pregnancy were explored., Methods: Semi-structured key informant interviews (n = 20) and one focus group discussion (n = 4) were conducted with healthcare providers working in one public hospital in Accra, Ghana. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes., Results: Most healthcare providers are aware of the importance of maternal mental health and would be keen to help women who experience mental ill-health during and after pregnancy, if resources were available to do so. An enabling factor was the suggestion of introducing a culturally appropriate mental health screening tool. However, compromised mental health was often considered a 'spiritual issue' and not routinely screened for by healthcare providers, nor requested by women. Barriers to the provision of quality maternal mental health care included lack of trained staff and lack of time., Conclusions: Healthcare providers are aware of the problem of the lack of maternal mental health provision during and after pregnancy and are open to developing protocols to improve care. Currently, screening for maternal mental ill-health is not part of routine maternity care. The establishment of such a service requires the reprioritisation of workloads, further training, and a change in the attitudes and practices of healthcare providers. Education to change the attitudes of healthcare providers, women and the wider community towards mental health is needed. The development and implementation of culturally appropriate guidelines would be beneficial and result in better quality of maternity care.