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Background: In India, current maternal mortality ratio is 97/100,000 livebirths, and still more efforts are needed to achieve Sustainable Development Goal 3, target 1 of 70/100,000 livebirths. Women die because of complications during and following pregnancy and childbirth. Skilled care during and immediately after delivery has been identified as one of the key strategies in reducing maternal mortality. Birth preparedness and complication readiness (BPCR) has been implemented as a comprehensive strategy to fill this gap. BPCR is one of the key interventions to reduce the maternal mortality. Materials and Methods: This was a community-based before and after interventional study (quasi-experimental study) and was conducted in two randomly selected primary health centers of South West district of Delhi. Results: A total of 152 community health workers (CHWs) took part in the study. About one fourth (22.03%) had knowledge regarding water breakage without labor, which increased to 85.53% after training and was statistically significant (P < 0.0001). Mean knowledge score preintervention was 4.35 (1.82), whereas the postintervention mean knowledge score was 8.98 (0.99) and was statistically significant (P < 0.0001) Conclusion: Though awareness of CHWs on some aspects of the BPCR components was good before the training program, marked improvement was seen in most of the domains after the training session. [ABSTRACT FROM AUTHOR]

BACKGROUND: The World Health Organization (WHO) in their 2018 guidelines favored a noninterventional approach toward the labor process. The active phase of labor will be initiated when the cervix is 5 cm dilated and during obsoleted use of a 1 cm/hour cervical dilation rate as a diagnostic test for abnormal birth outcomes. OBJECTIVES: The aim of the study is to compare an active interventional labor management approach to a noninterventional labor management approach in nulliparous parturient women in terms of need of intervention, mode of birth, and maternofetal outcome. METHODOLOGY: This randomized control study was conducted at a rural tertiary care hospital for a period of 1.5 years. Nulliparous low-risk pregnant women presenting in latent labor were randomly allocated into two groups on the basis of cervical dilation and labor intervention. WHO 2014 guidelines with partograph were followed in group 1, and 2018 WHO guidelines with labor care guide were followed in group 2. RESULT: Both the groups were comparable with age, parity, and Bishop score at the time of admission. The incidence rates of intervention in the active first stage of labor in group 1 and group 2 were 31% and 10% with an odds ratio of 0.192 (95% confidence interval [CI] [0.079, 0.466]), and the rates of lower segment cesarean section in both the groups were 17.6% and 5.8%, respectively. The odds ratio with 95% CI for postpartum hemorrhage and neonatal intensive care unit admission in group 1 compared with group 2 was 0.313 [0.061, 1.610] and 1.057 [0.143, 7.832], respectively. CONCLUSION: This study showed that the shifting of the active first-stage threshold by 1 cm and letting labor progress at its natural pace significantly reduced the need for intervention and affected the fetal and maternal outcome positively. [ABSTRACT FROM AUTHOR]

Background: Birth preparedness and complication readiness is a holistic approach that empowers mothers and families with the knowledge, attitude, and resources to alleviate potential challenges during childbirth. Despite its benefits, husbands' participation in maternal care differs significantly between countries and regions. There is a lack of previous studies that look at husbands' responses to birth preparedness and complication readiness in the research area. Thus, the primary goal of this study is to find out how husbands who have wives with infants under 12 months old feel about birth preparation, readiness for problems, and its associated factors. Methods: A community-based cross-sectional study design was conducted from May 30 to July 29, 2022. Simple random sampling was employed to select 499 husbands. An interviewer-administered, structured, and pretested questionnaire was used to collect the data. Data entry and analysis were performed using Epi Data version 4.6 and SPSS version 25, respectively. We used multivariable logistic regression to find statistically significant factors. P-values less than 0.05, 95% confidence intervals, and adjusted odds ratios are used to declare statistical significance. The findings were shown in figures, tables, and text. Results: The study found that 55.9% (95% CI: 51.4 to 61.4%) of husbands responded to birth preparedness and complication readiness. This response was significantly associated with being employed (AOR = 3.7, 95% CI: 2.27–5.95), engaging in self-business (AOR = 5.3, 95% CI: 2.34–12.01), having wives who delivered in health facilities (AOR = 7.1, 95% CI: 3.92–12.86), accompanying wives for antenatal care (AOR = 2.2, 95% CI: 1.39–3.56), possessing good knowledge of danger signs during labor (AOR = 2.0, 95% CI: 1.08–3.74) and the postnatal period (AOR = 7.1, 95% CI: 3.14–16.01). Interestingly, residents living near a health facility (AOR = 0.6, 95% CI: 0.39–0.97) were less likely to respond. Conclusion: The present study found that nearly 6 out of 10 husbands actively responded in terms of birth preparedness and complication readiness. While husbands in this study showed some involvement in birth preparedness and complications, it is good when compared to studies carried out nationally. To improve this, educating husbands by focusing on the danger signs and their role in childbirth is recommended. [ABSTRACT FROM AUTHOR]

Introduction: Urogenital fistula is a physically, socially and psychologically devastating condition for the patient. In developed countries, these fistulae are typically related to gynecological surgery, pelvic pathology like malignancy or post radiation therapy. In contrast, classical teaching is that urogenital fistulae in the developing countries like India are usually associated with prolonged labor and obstetric complications. This retrospective study conducted at a tertiary care health Institute shows a paradigm shift in epidemiology, etiology and management of genitourinary fistulae in India in recent times. Methods: This retrospective study included patients undergoing surgical repair for various genitourinary fistulae at our institute from 2016 to 2022. Epidemiology, etiology, site, size and number of fistulae, clinical presentation, and management records of these patients were recorded and reviewed retrospectively. Results: In our study, the mean age of the patients was 38.4 ± 10.2 years. Vesicovaginal Fistula (VVF) was found to be most common fistula in the study population (87.5%) followed by vesicouterine (7.1%) and urethrovaginal fistula (5.4%). The causes of genitourinary fistula were iatrogenic (73.2%), carcinoma of cervix (16.1%), obstructed prolonged labor (7.1%), and genitourinary tuberculosis (3.57%). Among the 48 vesicovaginal fistulas that underwent surgery, 45.8% were treated using a transvaginal approach, 29.2% were managed through a laparoscopic transabdominal repair, and 25% were addressed using a robotic approach. Recurrence occurred in 7.1% of the operated patients. Conclusion: Enhanced healthcare services in the country have contributed to a decrease in the incidence of obstructed labor, subsequently reducing related injuries. Iatrogenic injuries resulting from gynecological surgeries and carcinoma cervix have given rise to more complex fistulas, necessitating the implementation of advanced treatment strategies. [ABSTRACT FROM AUTHOR]

A Cross-sectional study to assess the level of Parental stress and coping strategies among Mothers attending Postnatal Areas of GMCH Sector-32, Chandigarh was carried out in full compliance with ethical standards provided by the Research and Ethical committee of GMCH-32, Chandigarh. The approval was taken to conduct research from the committee of the institution. The objectives of the study were to assess the level of Parental stress among Mothers attending Postnatal Areas of GMCH Sector-32, Chandigarh, to assess the coping strategies of Mothers attending Postnatal Areas of GMCH Sector-32, Chandigarh, To find out the association of Parental stress with selected socio-demographic variables. Data was collected by using parental stress scale and self-efficacy scale from 100 study subjects from Postnatal Areas (labour room, postnatal ward and immunization).The sampling technique used was convenience sampling . The study concluded that 55% of the mothers were suffering from moderate stress, 19% were having severe stress and 26% mothers were having mild stress.16% mothers were having low level coping, 60% were having medium level coping and 24% mothers had high level of coping. Thus moderate amount of stress and medium level of coping were found to be more in Postnatal mothers. Association between parental stress and gravida of mother was found to be significant with p value =0.05 . [ABSTRACT FROM AUTHOR]

Background: Childbirth is a transformative process. Modern healthcare offers pharmacological and non-pharmacological interventions for safe and improved childbirth experience. Studies have found that maternal mobility during the first stage of labour has a significant effect on maternal and child outcomes. A pilot study was done to find the effect of mobility during the first stage of labour on maternal satisfaction and foetal outcome. Method: An experimental study was done with 60 primigravida women with uncomplicated antenatal history reporting to the labour room of a tertiary care government hospital in Delhi chosen as study participants. Validated and reliable tools were used to measure labour, maternal and neonatal outcomes within 24 h post-delivery. Results: The results showed that there was an impact on mobility intervention during the first stage of labour on parturition (p =.03) and significant maternal satisfaction (p =.001). However, the neonatal outcome of both groups was not significant. Conclusion: Mobility was an effective non-pharmacological intervention for enhancing parturition and maternal satisfaction. Mobility during the first stage of labour can be recommended for practice guidelines for all midwives in the labour room as a protocol. [ABSTRACT FROM AUTHOR]

Background: Fear of giving birth is the primary factor that has reduced the preference for natural birth. The sudden rise in the percentage of C-sections has harmed women's pregnancy and new-born health. Purpose: To evaluate the effectiveness of peanut ball exercise on reducing fear among primigravida mothers. Materials and Methods: Thirty participants were randomly assigned to experimental (peanut ball exercise, antenatal exercise, antenatal education) and conventional (Antenatal exercises) groups. The fear of childbirth questionnaire (FCQ) was used to evaluate the pre-test the same test used to determine post-treatment values after 12 weeks of the treatment. Results: A significant difference was observed between the experimental and control groups (P =0.0001). peanut ball exercise and antenatal education were effective in mothers with a fear of childbirth. Conclusion: Peanut ball training is effective in mothers with a fear of childbirth. [ABSTRACT FROM AUTHOR]

Background and objectives: To ascertain the prevalence of obstructed labour and to research numerous risk variables that affect obstructed labour To research the problems related to pregnancy and birth and, investigate about maternal and perinatal deaths in addition to the numerous variables that contribute to these losses. To Discuss methods for reducing obstructed labour with the available resources. Methods: A prospective study was carried out for a full year, from January 2020 to December 2020, in the Obstetrics and Gynaecology Department at Kurnool Medical College, Kurnool, Andhra Pradesh, India, in which all term pregnant women with obstructed labour who attend labour room emergency referred from outlying health care facilities were included. Results: In the present study, 69% of the cases were 21 to 30 years old, followed by 19% aged 21 and 12% aged 31 and older. Mean height was 142.7+ 4.0 cm. 59.5% of the pregnant women were primigravida, followed by second (16.7%) and third (11.9%) gravidas. 14.7% of cases with a labour duration of 24 hours had PPH and 62.5% of cases with a labour duration >24 hours had PPH. 11.8% of cases with a duration of labour 24 hours and 50% of cases with a duration of labour >24 hours had APGAR of 0, and 50% of cases with a duration of labour 24 hours and 0% of cases with a duration of labour >24 hours had APGAR of 10. Conclusion: Even though obstructed labour is preventable, it still significantly increases mother and infant morbidity in our country. As a result, prevention is better than treatment. Enhancing remote healthcare can reduce incidence. [ABSTRACT FROM AUTHOR]

Though there are multitudes of analgesic techniques available to relieve labor pain, epidural analgesia is considered as most effective against labor pain. Many studies have investigated whether and how the epidural analgesia may have an impact on the first and second stage of labor, maternal and neonatal outcomes and birth experience but the results are still controversial. There was an interest to analyze on delivery outcomes of Bloom Life Hospital at Chennai, on the delivery outcomes (maternal and fetal) on using Epidural analgesia (0.2% ropivacaine + 50 mic Fentanyl). Data was accessed from bloom Life Hospital (N= 223 parturients) administered with Epidural analgesia between April 2015 to October 2021. The obtained data was coded and the preliminary analysis was performed descriptively analyzed. The descriptive analysis revealed that among 223 parturients who received EA 89% (N=174) had Normal Vaginal delivery. Only 28 among the study participants (12.5%) had ins/outlet forceps delivery. Neonatal outcomes revealed that 138 among 224 babies did not require NICU admission. The study data has clearly revealed that Epidural Analgesia did not increase the rates of CSection. In Future, prospective study has been planned to know the impact of EA on labor, delivery, maternal and fetal outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The quality of maternity care in Tamil Nadu has significantly improved in the past few years and various public health initiatives have helped to reduce crucial indicators like Maternal Mortality Ratio and Infant Mortality Rate. The improvement in quality of interface between the mothers and service providers in term of language, behaviour and attitude for ensuring 'Respectful Maternity Care' would support further enhancement of maternal and new born outcomes. Delivery of appropriate and respectful care to each pregnant woman would not only go a long way in reducing mortality and morbidity for the woman and new-born but also help in improved cognitive development of the baby. Objective: To assess the quality of delivery care practices provided during normal delivery among women accessing public health facilities in Tamil Nadu. Methods: A descriptive evaluation study was conducted from May to December 2018 in 16 facilities across 14 districts in Tamil Nadu. The health facilities were stratified according to the level of services, Government Medical College hospitals (MC), District headquarter hospitals (DHQ), Sub-district hospitals (SDH), and PHCs, 4 facilities in each category were selected. Data was collected by direct observation using a facility observation check list in an Android-based tablet application. Informed consent was obtained from all participants. Results: A total of 1006 pregnant women out of 2242 women who had normal delivery were assessed and included in the study. More than 50% of deliveries were conducted by nurses and midwives and the perinatal and maternal outcomes were found to be good. The parameters for the respectful maternity care were recorded. Routine care monitoring parameters helped to reduce mortality rate and improved delivery care. Conclusion: The state though has achieved substantial success in promoting institutional delivery practices, still needs certain crucial improvements in the quality of respectful maternal care during the delivery. Significance: The overall pooled prevalence of disrespectful maternity care in India was 71.31% (95% CI 39.84–102.78) where every individual study prevalence ranged from 20.9 to 100%. Institutional delivery is 100 percent in Puducherry and Tamil Nadu (NFHS V) and hence it is important to assess the quality of maternity care provided in public healthcare facilities in the state. The improvement in the quality of the interface between the women and service providers in terms of language, behavior, and attitude for ensuring 'Respectful Maternity Care' would thus contribute to positive outcomes for women and their newborns, and also to ensure the cognitive development of children later in life. [ABSTRACT FROM AUTHOR]

Introduction: Cervical assessment has moved from digital examination to sonographic evaluation in recent years. Predicting the time of onset of labour and mode of delivery at term is a great concern for both the pregnant woman and her relatives. Aim: To predict the time of onset of labour and mode of delivery by Transvaginal sonographic measurement of cervical length at term. Materials and Methods: This longitudinal study was conducted in the Department of Obstetrics and Gynaecology, SRM Medical College Hospital and Research Centre, Kattankalathur, Tamil Nadu, India, from March 2021 to August 2021. All low-risk singleton pregnancies between 38-40 weeks of gestation were included. Cervical length (in mm) was measured transvaginally by the principal investigator between 38 and 40 weeks. When the labour sets in the duration between cervical length measurement and the onset of labour, duration of labour and mode of delivery were noted. Pearson correlation coefficient was used to quantify the association between cervical length and time of onset of labour and duration of labour. Results: In the study, 164 low-risk patients (143 Primigravida patients+21 Multigravida patients) between 38-40 weeks were included. In patients with spontaneous onset of labour, 45 (70.3%) had labour onset within 120 hours (5 days) when cervical length was ≤30 mm, when compared with 7 (22.58%) when cervical length was >30 mm (p=0.001). In patients with cervical length ≤30 mm, vaginal delivery occurred in 47 (73.43%) (p=0.019). In women with induced labour with cervical length =30 mm, 13 (61.9%) had labour onset within 120 hours when compared to 15 (30.6%) in women with cervical length >30 mm (p=0.02). Vaginal delivery occurred in 5 (29.41%) of women when cervical length was =30 mm compared to 32 (65.30) in women when cervical length >30 mm which may be attributed to other causes. There was a significant positive correlation between cervical length and time of onset of labour (Correlation coefficient=0.221, p-value=0.004). There was a negative correlation between cervical length and duration of labour which was not statistically significant (Correlation coefficient=-0.108, p=0.25). There was no significant difference in mean cervical length measurement between vaginal delivery and caesarean section. Conclusion: Transvaginal cervical length measurement at term positively correlates with time of onset of labour but not with duration of labour and mode of delivery. [ABSTRACT FROM AUTHOR]

Purpose: Labor pain is one of the most agonizing pains experienced by all delivered women. Many pharmacological agents used in labor analgesia require intense monitoring facilities, which are not available in routine obstetric practice in low-resource settings. This study aimed to compare the efficacy of intravenous (IV) paracetamol and intramuscular (IM) tramadol on labor pain relief, labor progression, and maternal and neonatal outcomes. Methods: This randomized drug trial was carried out on 110 women divided into two groups. Group A women received 1000 mg of IV paracetamol, and Group B women received 100 mg of IM tramadol during the active phase of labor. Pain intensity was assessed by the Visual Analogue Scale (VAS) at intervals till 120 min of delivery. The maternal and neonatal outcomes were recorded. Results: There was a statistically significant fall in pain score till 180 min of drug administration in the paracetamol group and 120 min in the tramadol group. At 180 min and 240 min, paracetamol is more effective than tramadol (p value 0.004 at 180 min and 0.0119 at 240 min). There were significantly low pain score levels at 60 min of delivery in the paracetamol group (p value—0.004). Nausea and vomiting were significantly higher in the tramadol group (p value 0.000013). Conclusion: Compared to IM tramadol, IV paracetamol has a longer duration of action and fewer maternal side effects, making it suitable for parenteral analgesia in labor. Due to a better safety profile, there is no need for intense maternal and fetal monitoring with IV paracetamol. Trial registration: Clinical Trials Registry—India (CTRI registration number—CTRI /2019/05/019244). [ABSTRACT FROM AUTHOR]

Background: The World Health Organization (WHO) Labour Care Guide (LCG) is a paper-based labour monitoring tool designed to facilitate the implementation of WHO's latest guidelines for effective, respectful care during labour and childbirth. Implementing the LCG into routine intrapartum care requires a strategy that improves healthcare provider practices during labour and childbirth. Such a strategy might optimize the use of Caesarean section (CS), along with potential benefits on the use of other obstetric interventions, maternal and perinatal health outcomes, and women's experience of care. However, the effects of a strategy to implement the LCG have not been evaluated in a randomised trial. This study aims to: (1) develop and optimise a strategy for implementing the LCG (formative phase); and (2) To evaluate the implementation of the LCG strategy compared with usual care (trial phase). Methods: In the formative phase, we will co-design the LCG strategy with key stakeholders informed by facility assessments and provider surveys, which will be field tested in one hospital. The LCG strategy includes a LCG training program, ongoing supportive supervision from senior clinical staff, and audit and feedback using the Robson Classification. We will then conduct a stepped-wedge, cluster-randomized pilot trial in four public hospitals in India, to evaluate the effect of the LCG strategy intervention compared to usual care (simplified WHO partograph). The primary outcome is the CS rate in nulliparous women with singleton, term, cephalic pregnancies in spontaneous labour (Robson Group 1). Secondary outcomes include clinical and process of care outcomes, as well as women's experience of care outcomes. We will also conduct a process evaluation during the trial, using standardized facility assessments, in-depth interviews and surveys with providers, audits of completed LCGs, labour ward observations and document reviews. An economic evaluation will consider implementation costs and cost-effectiveness. Discussion: Findings of this trial will guide clinicians, administrators and policymakers on how to effectively implement the LCG, and what (if any) effects the LCG strategy has on process of care, health and experience outcomes. The trial findings will inform the rollout of LCG internationally. Trial registration: CTRI/2021/01/030695 (Protocol version 1.4, 25 April 2022). Plain language summary: The new WHO Labour Care Guide (LCG) is an innovative partograph that emphasises women-centred, evidence-based care during labour and childbirth. Together with clinicians working at four hospitals in India, we will develop and test a strategy to implement the LCG into routine care in labour wards of these hospitals. We will use a randomised trial design where this LCG strategy is introduced sequentially in each of the four hospitals, in a random order. We will collect data on all women giving birth and their newborns during this period and analyse whether the LCG strategy has any effects on the use of Caesarean section, women's and newborn's health outcomes, and women's experiences during labour and childbirth. While the trial is being conducted, we will also collect qualitative and quantitative data from doctors, nurses and midwives working in these hospitals, to understand their perspectives and experiences of using the LCG in their day-to-day work. In addition, we will collect economic data to understand how much the LCG strategy costs, and how much money it might save if it is effective. Through this study, our international collaboration will generate critical evidence and innovative tools to support implementation of the LCG in other countries. [ABSTRACT FROM AUTHOR]

Introduction: Epidurally administered local anesthetics provide most effective analgesia during labour process. Among the available local anesthetics Bupivacaine and ropivacaine are the most commonly used drugs in concentrations ranging from 0.0625% to 0.125% and 0.08% to 0.125%, respectively. Both these drugs are weak bases, highly protein bound, highly lipid soluble, and have a pKa of 8.1, low unionised fraction, thus having a slightly longer time for onset of action but with a longer duration of action and have less transfer across the placenta. Hence, they are ideal drugs for use in labour analgesia. Aim: To compare the effectiveness of programmed intermittent bolus of 0.125% bupivacaine and 0.125% ropivacaine in low volumes in full term primigravidas for epidural labour analgesia. Materials and Methods: This randomised clinical study was conducetd at PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India, between June 2020 and December 2021 among 80 full term primi parturients requiring normal vaginal delivery. They were randomly divided into two groups of 40 each. Group B received 10 mL of 0.125% bupivacaine and group R received 10 mL of 0.125% ropivacaine as initial bolus dose. Repeat doses of 5 mL was given every 60 minutes or when the patient had Visual Analogue Score (VAS) score >4 with a maximum dose of 10 mL/hr with a 20 minute interval between two doses. Parameters assessed were onset, duration, level and quality of analgesia, motor blockade, number of epidural top ups, total volume of drug consumed, mode of delivery, duration of labour, APGAR score, haemodynamics, patient satisfaction and complications. Data was entered in Microsoft Excel 2010 version and analysed using Statistical Package for Social Sciences (SPSS) version 20.0. Results: Both drugs were equally effective in terms of analgesia, maternal and foetal outcomes. Bupivacaine had a faster onset of action (7.075±0.916 min) compared to ropivacaine (8.225±0.891 min) (p-value=0.001). Ropivacaine had a shorter duration of action (43.1±2.30 min vs. 47.9±4.16 min in group B) (p-value=0.0001), requiring more top-up doses (5.2±0.46 versus 4.77±0.61 in group B) (p-value=0.0007), and more total volume of drug (38.5±3.08 mL versus 35.5±4 mL in group B) (p-value=0.002). It also caused lesser motor blockade (Bromage score of 1 in 1 parturient vs. 8 parturients in group B) (p-value=0.0129) and better overall maternal satisfaction score (excellent) in 30 parturients versus 25 parturients in group B. APGAR scores at 1 minute and 5 minutes were comparable between the two groups. Mean heart rates, mean blood pressures were also comparable between the two groups. There were no significant adverse effects in either groups. Conclusion: By providing minimal motor blockade and adequate analgesia 0.125% ropivacaine allows parturients to go through the labour process with excellent maternal satisfaction and minimal adverse effects compared to 0.125% bupivacaine. [ABSTRACT FROM AUTHOR]

Introduction: Safe motherhood ensures safe pregnancy and childbirth. One of the noteworthy causes of maternal morbidity and mortality is the complications arising from prolonged or obstructed labour. World Health Organization recommends the use of partograph to significantly reduce the maternal mortality crisis. This study aimed to evaluate the effectiveness of a novel partograph in terms of maternal and perinatal outcomes along with its utility. Materials and Methods: A total of 400 intranatal women were selected in a non-randomized control trial to evaluate the effectiveness of novel partograph on selected maternal and perinatal outcomes. Subjects in experimental group (n=200) received care with newly developed partograph whereas subjects in control group (n=200) received standard care. Effectiveness was determined at a significance level of α ≤ 0.05. Utility of the novel partograph was determined as perceived by nurses. Results: There was significant reduction in the duration of the 1st and 2nd stage of labour (P=0.023 and 0.006 respectively) and number of vaginal examinations performed during labour (P=0.017) among mothers in the experimental group. Significant improvement in the Apgar score (P=0.005) was also observed among the infants of mothers in experimental group. Novel partograph was considered as of having extreme utility by 71% nurses. Conclusion: Study concluded that subjects monitored by the partograph experienced improved maternal and perinatal outcomes. It was found to be having extreme utility. [ABSTRACT FROM AUTHOR]

Background: India's neonatal and perinatal mortality is among the highest in the world. Intrapartum-related conditions contribute to a significant proportion of neonatal deaths and stillbirths. Fetal heart rate monitoring, a recommended norm to assess fetal well-bring, is not practiced as per standard guidelines in public health facilities. A standardized Doppler along with training on fetal heart rate monitoring was implemented across different levels of healthcare in three states. Methods: Facilities were selected purposively to implement the Doppler. Baseline data for 3 months were collected. Interviews of health providers and observation of labor were conducted quarterly. Data were analyzed through a comparison of baseline and intervention on a number of delivery and monitoring indicators. Results: Among 22,579 total deliveries, monitoring frequency increased along with increase in detection of abnormal fetal heart rate (FHR) while cesarean section and stillbirths reduced slightly. Cases never monitored reduced in the District Hospitals (7.98–2.07, P < 0.01) and in Community Health Centers (14.7–1.67, P < 0.001). Stillbirth rate reduced at the medical college (3.6–1.1, P < 0.001). Interviews with providers revealed acceptance of the device due to its reliable readings. Conclusion: The Doppler demonstrates acceptability and serves as a useful aid to improve intrapartum FHR monitoring. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The present prospective observational study was conducted to study the incidence, indications, and outcomes of induction of labor in a tertiary care center. MATERIAL AND METHOD: The study group of this prospective cross-sectional study was constituted by all term pregnant women underwent trial of labor. The whole study group was further subdivided in two groups, group 1: Was having all pregnant women with spontaneous onset of labor pains and group 2 was containing all pregnant women underwent induction of labor. For induction only prostaglandins (PGE1 25 microgram tablet and PGE2 gel) were used. The measure of outcome included assessment of the incidence of induction in term pregnant women, major indications of induction of labor, duration of labor, mode of delivery, intrapartum and postpartum maternal-fetal complications and duration of hospital stay. The study group included 3264 pregnant women and was differentiated into group 1 with 2,588 pregnant women and group 2 with 676 pregnant women. RESULTS: The incidence of induction was 20.71%. Major indications of induction were a fetus who was postdates, premature rupture of membranes, and preeclampsia. The average duration of the induction to delivery interval was 19.13 ± 15.14 hours (hrs.) and admission to delivery interval in the spontaneous labor group was 8.79 ± 07.18 hrs. The incidence of cesarean delivery was 19.52% in the induction group (gp2). Failed induction was the most common indication of lower segment cesarean section (CS). The incidence of CS was 15.99% in spontaneous group (gp1) and fetal distress was most common indication in this group. With this study, we found the importance of rest after the induction process was completed. During this watchful rest period, 51 pregnant women delivered vaginally. The neonatal intensive care unit (NICU) admission and neonatal death rate was more in group 1. CONCLUSION: This study revealed that the incidence and indications of induction of labor among term pregnant women were similar to developed countries in spite of active physical life. The complication rate, operative intervention and hospital stay was more with induction group. [ABSTRACT FROM AUTHOR]

Background: Evidence on obstetric violence is reported globally. In India, research shows that almost every woman goes through some level of disrespect and abuse during childbirth, more so in states such as Bihar where over 70% of women give birth in hospitals.Objective: 1) To understand how women experience and attach meaning to respect, disrespect and abuse during childbirth; and 2) document women's expectations of respectful care.Methods: 'Body mapping', an arts-based participatory method, was applied. The analysis is based on in-depth interviews with eight women who participated in the body mapping exercise at their homes in urban slums and rural villages. Analysis was guided by feminist relational discourse analysis.Findings: Women reported their experiences of birthing at home, public facilities, and private hospitals in simple terms of what they felt 'good' and 'bad'. Good experiences included being spoken to nicely, respecting privacy, companion of choice, a bed to rest, timely care, lesser interventions, obtaining consent for vaginal examination and cesarean section, and better communication. Bad experiences included unconsented interventions including multiple vaginal examinations by different care providers, unanesthetized episiotomy, repairs and uterine exploration, verbal, physical, sexual abuse, extortion, detention and lack of privacy.Discussion: The body maps capturing birth experiences, created through a participatory method, accurately portray women's respectful and disrespectful births and are useful to understand women's experience of a sensitive issue in a patriarchal culture. An in-depth understanding of women's choices, experiences and expectations can inform changes practices in and policies and help to develop a culture of sharing birth experiences. [ABSTRACT FROM AUTHOR]

The main objective of this study was to determine the microbial contamination and antimicrobial resistance pattern among isolated bacteria from the environment surfaces of maternity units and labor rooms of healthcare facilities in the Gujarat state of India. The cross-sectional study was conducted in ten healthcare facilities, where the microbiological swab samples were collected from various pre-decided environmental surfaces of the maternity and labor rooms as part of the Water, Sanitation and Hygiene (WASH) assessment. The swabs were analyzed by conventional microbiological culture methods to identify microorganisms, including antimicrobial susceptibility testing. The study provides an insight into the microbial contamination of the visibly clean areas, i.e., the maternity ward, labor room, and general wards of the healthcare facilities. The labor rooms were found to be highly contaminated in comparison to other selected sites. The microbiological findings revealed a predominance of Gram-negative bacteria, specifically Pseudomonas species. The antibiotic susceptibility testing indicates resistance against many commonly used antibiotics. This study produces an identified necessity for enhancing microbiological surveillance in labor rooms and maternity units. This study also highlights the importance of microbiological status along with the WASH status of healthcare facilities. [ABSTRACT FROM AUTHOR]

In this paper, we draw on three ethnographic studies of surrogacy we carried out separately in different contexts: the western US state of California, the south Indian state of Karnataka, and the western Russian metropolis of St Petersburg. In our interviews with surrogate mothers, intended parents, and surrogacy professionals, we traced the meanings and ideologies through which they understood the clinical labour of surrogacy. We found that in the US, interviewed surrogates, intended parents and professionals understood surrogacy as an exchange of both gifts and commodities, where gift-giving, reciprocity, and relatedness between surrogates and intended parents were the major tropes. In India, differing narratives of surrogacy were offered by its different parties: whilst professionals and intended parents framed it as a win-win exchange with an emphasis on the economic side, the interviewed surrogate mothers talked about surrogacy as creative labour of giving life. In Russia, approaches to surrogacy among the interviewed surrogate mothers, professionals and intended parents overlapped in framing it as work and a businesslike commodity exchange. We suggest these three different ways of ethical reasoning about the clinical labour of surrogacy, including justifications of women's incorporation into this labour, were situated in local moral frameworks. We name them "repro-regional moral frameworks", inspired by earlier work on moral frameworks as well as on reproductive nationalisms and transnational reproduction. Building on these findings, we argue that any international or global regulation of surrogacy, or indeed any moral stance on it, needs to take these local differences into account. [ABSTRACT FROM AUTHOR]

The Government of India initiated the Beti Bachao Beti Padhao (B3P) programme in 2015 as a flagship initiative to reduce gender imbalance in sex ratio at birth (SRB) and to ensure social protection of girls. The present study was conducted to evaluate the medium-term impact of B3P implementation in Haryana state, from 2015 to 2019, on SRB. Monthly data on SRB were collected for the entire state of Haryana through a civil registration system. Segmented time series regression analysis was used to estimate the variations in SRB after the B3P programme with the help of Winter's additive interrupted time series model. The SRB in Haryana increased from 876 girls per 1000 boys in 2015 to 923 in 2019. The results of the model demonstrated that before the inception of intervention (pre-slope), there was a significant monthly change in SRB of 0.217 (95% confidence interval: 0.144-0.290). Following the B3P programme, SRB was found to increase by 0.835 per month, which implied that an increase of 0.618 (confidence interval: 0.338, 0.898) every month in SRB can be attributed to the B3P programme. This indicated that SRB for the state of Haryana increased at the rate of 7.42 units per year as a result of the B3P programme. B3P has led to a significant improvement in SRB in Haryana state. The continuity of efforts in the same direction with a sustained focus on behaviour change will further help achieve the goal of gender parity in births and child survival. [ABSTRACT FROM AUTHOR]

Background: Timely and skilled care is key to reducing maternal and neonatal mortality. Birth preparedness involves preparation for safe childbirth during the antenatal period to reach the appropriate health facility for ensuring safe delivery. Hence, understanding the factors associated with birth preparedness and its significance for safe delivery is essential. This paper aims to assess the levels of birth preparedness, its determinants and association with institutional deliveries in High Priority Districts of Uttar Pradesh, India.Methods: A community-based cross-sectional survey was conducted between June-October 2018 in the rural areas of 25 high priority districts of Uttar Pradesh, India. Simple random sampling was used to select 40 blocks among 294 blocks in 25 districts and 2646 primary sampling units within the selected blocks. The survey interviewed 9458 women who had a delivery 2 months prior to the survey. Descriptive statistics were included to characterize the study population. Multivariable logistic regression analyses were performed to identify the determinants of birth preparedness and to examine the association of birth preparedness with institutional delivery.Results: Among the 9458 respondents, 61.8% had birth preparedness (both facility and transportation identified) and 79.1% delivered in a health facility. Women in other caste category (aOR = 1.24, CI 1.06-1.45) and those with 10 or more years of education (aOR = 1.68, CI 1.46-1.92) were more likely to have birth preparedness. Antenatal care (ANC) service uptake related factors like early registration for ANC (aOR = 1.14, CI 1.04-1.25) and three or more front line worker contacts (aOR = 1.61, CI 1.46-1.79) were also found to be significantly associated with birth preparedness. The adjusted multivariate model showed that those who identified both facility and transport were seven times more likely to undergo delivery in a health facility (aOR = 7.00, CI 6.07-8.08).Conclusion: The results indicate the need for focussing on marginalized groups for improving birth preparedness. Increasing ANC registration in the first trimester of pregnancy, improving frontline worker contact, and optimum utilization of antenatal care check-ups for effective counselling on birth preparedness along with system level improvements could improve birth preparedness and consequently institutional delivery rates in Uttar Pradesh, India. [ABSTRACT FROM AUTHOR]

Objectives: The study aimed to assess the functionality of labour rooms by evaluating the labour room infrastructure with reference to the standard guidelines, the status of the availability of human resources, the availability of essential equipment and consumables in the labour room and by documenting the knowledge of the healthcare provider in terms of labour room practices. The study also explored the facility parameters associated with its delivery load taking the facility as a unit of analysis. Design: A cross-sectional analytical study. Setting: India has realised the importance of improving the quality of care in public health facilities, and steps are being taken to make healthcare more responsive to women's needs. With an increase in the proportion of institutional deliveries in India, the outcome of the delivery process can be improved by optimising the health facility components. Participants: The study was conducted in 52 health facilities and healthcare providers involved in the delivery process in the selected facilities. Results: The infrastructure of the facilities was found to be the best for medical college followed by district hospitals, Community Health Centres (CHCs), Primary Health Centres (PHCs) and subcentres. Similar findings were observed in terms of the availability of equipment and consumables. Lack of healthcare providers was observed as only 20% of the posts for health personnel were fulfilled in CHCs followed by PHCs, subcentres and district hospitals where 43, 50 and 79% of the available vacancies were fulfilled. The level of knowledge of healthcare providers in terms of partograph, active management of the third stage of labour and post-partum haemorrhage ranged as per their designation. The specialists were the most knowledgeable while the Auxiliary Nurse Midwife (AMNs) were the least. All the components of structural capacity, i.e. infrastructure (r2 = 0.377, P value < 0.001), equipment and consumable (r2 = 0.606, P value < 0.001) and knowledge of healthcare providers (r2 = 0.456, P value < 0.001) along with the overall facility score were positively correlated with the average delivery load of the health facility. The results from multivariate linear regression depict significant relation between the delivery load and availability of equipment and consumables (t = 4.015, P < 0.01) and with the knowledge of healthcare providers (t = 2.129, P = 0.039). Conclusions: The higher facilities were better equipped to provide delivery and newborn care. A higher delivery load was found at high-level facilities which can be attributed to better infrastructure, adequate supply of equipment and consumables and availability of trained human resources. [ABSTRACT FROM AUTHOR]

Background: The experience of labour is complex and subjective. However, as a consistent finding, labour pain is ranked high on pain rating scale when compared to other painful life experiences. So, a change can affect all dimensions of pregnant women and her family life. Aim: The aim of this study was to assess the level of awareness of labour analgesia among the women in rural northern India and factors which prevent them from opting for labour analgesia. Material and Methods: This was a cross sectional Questionnaire based study conducted in Government Medical College, Kathua, J&K. A self-made Questionnaire was used to obtain demographic details, awareness and attitude of pregnant women towards labour analgesia. A total of 300 women took part in the study. Data was analysed by SPSS 20. Frequencies and percentages were calculated to express the results. Results: Out of 300 women, 68% belonged to rural areas. 10% of the women could not read or write. 84% of the women were unaware of labour analgesia. Out of aware participants, no one got the information from primary health care workers like Asha worker or a midwife. About 86% of the participants said that the labour pains are either severe or unbearable, yet only 32% were ready to take labour analgesia. Out of unwilling participants, about 40% of the women believed that it would be harmful to their baby. Conclusion: Majority of the women believed that the labour pains are severe to unbearable yet desire to bear pain is prevalent. Health care workers should be trained to deliver knowledge about labour analgesia to all women in antenatal period. [ABSTRACT FROM AUTHOR]

Objectives: Induction of labour (IOL), or starting labour artificially, can be a lifesaving intervention for pregnant women and their babies, and rates are rising significantly globally. As rates increase, it becomes increasingly important to fully evaluate all available data, especially that from low income settings where the potential benefits and harms are greater. The goal of this paper is to describe the datasets collected as part of the Induction with Foley OR Misoprostol (INFORM) Study, a randomised trial comparing two of the recommended methods of cervical ripening for labour induction, oral misoprostol and Foley catheter, in women being induced for hypertension in pregnancy, at two sites in India during 2013–15. Data description: This dataset includes comprehensive data on 602 women who underwent IOL for hypertensive disorders in pregnancy. Women were randomly assigned to cervical ripening with oral misoprostol or a transcervical Foley catheter in two government hospitals in India. The main dataset has 367 variables including monitoring during the induction of labour, medications administered, timing and mode of delivery, measures of neonatal morbidity and mortality, maternal mortality and morbidity, maternal satisfaction and health economic data. The dataset is anonymised and available on ReShare. [ABSTRACT FROM AUTHOR]

Background: Effective communication between health-care providers (HCP) and women during labor is a key component for providing dignified and consented maternity care. The quality improvement (QI) study was planned to improve the communication skills of HCP to provide dignified and consented care in the labor ward. Methodology: This study was conducted at the labor ward of a tertiary care hospital. To assess the magnitude of nondignified and nonconsented care, baseline data were collected from the women who had normal vaginal delivery through interviews using a prestructured questionnaire. The HCPs were also interviewed about the reasons for nondignified and nonconsented care. Various change ideas were tested through the plan-do-study-act cycle to sensitize the HCP with World Health Organization recommendations on intrapartum communication. Results: There was a marked improvement in communication between HCP and women in labor, i.e., addressing the woman by her name (100%), consent before each clinical examination (93%), and providing information about the progress of labor after each examination (50%). Conclusion: A QI approach is feasible and effective as a behavior change intervention to provide dignified and consented care in the existing settings. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to determine the association of intrapartum risk factors and infant clinical indicators using the National Institute for Health and Care Excellence (NICE) criteria with culture-positive early-onset neonatal sepsis (EONS) from a rural secondary healthcare facility where intrapartum prophylactic antibiotics are routinely administered to high-risk mothers.Methods: A single-center prospective observational study was conducted between July 2017 and September 2018. All intramural neonates with at least one NICE criteria at less than 72 h of life, were included. Univariate logistic regression and multivariable logistic backward elimination analyses were conducted to investigate individual risk factors and predictive models for culture proven EONS.Results: Of 236 newborns who were at risk for EONS by NICE criteria, 32 (13.8%) had positive blood cultures. Klebsiella species (n = 13, 39.4%) and Acinetobacter species (n = 11, 33.3%) were the most common isolated bacteria. In univariate analysis, the number of infant clinical indicators were associated with culture positive EONS (OR 1.36; 95% CI 1.01-1.81), but not the number of intrapartum risk factors (OR 0.76; 95% CI 0.4-1.29). The multivariate logistic regression with backward elimination procedure suggested that a model including absolute neutrophil count [adjusted OR (aOR) 0.81; 95% CI 0.72-0.92], C-reactive protein (aOR 1.24; 95% CI 1.08-1.43) and the number of clinical indicators (aOR 1.29; 95% CI 0.93-1.80) could be useful to predict culture positive EONS in our setting.Conclusion: In this maternal and neonatal cohort, infant clinical indicators rather than intrapartum risk factors were associated with culture confirmed EONS. [ABSTRACT FROM AUTHOR]

Introduction: India contributes to about 18% of global maternal deaths and 22.6% of still births. Efforts to improve the quality of care are challenged by the lack of reliable documentation of data. Hence, a concise, structured maternity case sheet (PrasavRecord) was designed with the aim to bring about an improvement in documentation of treatment and events related to woman in labour from the time of admission till her discharge from the hospital. Aim: To study the improvement in quality of documentation from the time of admission till discharge of a woman in labour with the help of structured format i.e., PrasavRecord. Materials and Methods: The study was conducted in February 2017. A quasi experimental study design was used, and the completeness of data recorded by the resident doctors in the existing hospital case sheet (control group) with those recorded in PrasavRecord (intervention group) were assessed in a total of 65 deliveries in each arm. Details of the patient from admission to the labour room followed by the entire sequence of events during labour as well as hospital stay in postpartum period were recorded over 130 parameters under different sections in PrasavRecord. Statistical analysis was done by using SPSS version 21.0. Results: Completeness of the documentation in terms of history, investigations and findings at examination including those at labour, nearly, 92% of the doctors rated PrasavRecord as "good and very good" for appearance, recommended its routine use, and 75% agreed that the format will be useful for conversion to electronic medical record. There was highly significant difference between the average percentage of completeness in PrasavRecord 75.8 {95% CI (74.2-77.4)} and hospital case sheets 42.2 {95% CI (40.9-43.6)} i.e., z=5.38 p-value <0.001. Conclusion: PrasavRecord is a simple, acceptable and user-friendly data entry format which improves the quality of documentation of the processes and practices during childbirth. Larger trials are required to finetune it to facilitate its widespread use thereby, ensuring a uniform documentation process of labour and postpartum. [ABSTRACT FROM AUTHOR]

Universal health coverage is central to the development agenda to achieve maternal and neonatal health goals. Although there is evidence of a growing preference for institutional births in India, it is important to understand the pattern of switching location of childbirth and the factors associated with it. This study used data from the fourth round of the National Family and Health Survey (NFHS-4) conducted in India in 2015-16. The study sample comprised 59,629 women who had had at least two births in the five years preceding the survey. Bivariate and multivariate logistic regression analyses were applied to the data. About 16.4% of the women switched their location of childbirth between successive births; 9.1% switched to a health facility contributing to a net increment of 1.9% in institutional delivery, varying greatly across states and regions. There was at least a 4 percentage point net increment in institutional births in Chhattisgarh, Bihar, Punjab and Haryana, but the shift was more in favour of home births in Madhya Pradesh, Odisha and West Bengal. Women with high parity and a large birth interval had higher odds of switching their place of childbirth, and this was in favour of a health facility, while women with higher education, from lower social groups, living in urban areas, who had not received four antenatal care visits, and who belonged to a higher wealth quintile had higher odds of switching their place of childbirth to a health facility, despite having lower odds of switching their childbirth location. The study provides evidence of women in India switching their location of childbirth for successive births, and this was more prevalent in areas where the rate of institutional delivery was low. Only a few states showed a higher net increment in favour of a health facility. This suggests that there is a need for action in specific states and regions of India to achieve universal health coverage. [ABSTRACT FROM AUTHOR]

Background: Rupture of the uterus carries major risk of maternal and perinatal morbidity and mortality especially in the developing world. Aims and Objectives: This study aims to identify retrospectively the risk factors leading to uterine rupture through case series and to determine the feto-maternal outcome of such serious clinical condition. Material and Methods: A retrospective study was done at Bankura Sammilani Medical College, Bankura, West Bengal, India from January 2014 to December 2018 to observe the incidence, aetiology, management and complications with maternal and foetal mortality and morbidity associated with rupture of the uterus in pregnant women at different gestational periods. The data were obtained from the case record section of the hospital. All rupture uterus cases were included excluding the dehiscence of scarred uterus. Results: Twentyone cases of Rupture Uterus were documented out of total delivery of 43,323 mothers in five years. There was a single maternal death and 15 (71.42 %) unbooked cases. Previous mode of delivery was found to be vaginal in 5 cases (23.8%). Most of the incidences of rupture uterus were scarred uterus (previous caesarean section and repaired uterus) 16 cases (76.19%), prolonged / obstructed labour 4 cases (19%), inductionof labour 1 (4.76%) and spontaneous rupture 1 (4.76%). Most cases were multiparous; site of rupture was in lower uterine segment in 18 cases (85.7%), fundal rupture 2 cases (9.52%) and left lateral 3 cases (14.2%). Bladder injury was in 1 case (4.76 %). Total abdominal hysterectomy was performed in 2 cases (9.52%) andsubtotal hysterectomy were done in 15 cases (71.4%); repair of the ruptured uterus wasperformed in 4 cases (19%). Fever and wound infections were present in 5 cases (23. 8%). Maternal death 1(4.76%) and 3 babies survived with perinatal mortality 18 (85.7%). Conclusion: Mandatory antenatal care, prompt diagnosis and safe instrumental delivery may change the rupture uterus incidences. [ABSTRACT FROM AUTHOR]

Objective: The aim of this research was to determine the rate and effects of second-stage cesarean delivery at a tertiary referral center. Materials and Methods: This retrospective cohort study reviewed case records of 105 women with singleton term pregnancies who underwent second-stage cesarean sections at the Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, in Rohtak, Haryana, India, from October 2018 to December 2019. Demographic, pregnancy, delivery, and neonatal details were noted. Feto–maternal complications were analyzed according to the method of impacted fetal head delivery and attempted assisted vaginal birth or not. Results: There was a cesarean section rate of 27.8% (4782/17,167) and a second-stage cesarean section rate of 2.3% (110/4782). Of 105 full-dilatation cesarean sections meeting the inclusion criteria, 72 (68.6%) were nulliparous, 94 (89.5%) had spontaneous labor, and 9 (8.5%) had previous cesarean sections. The most-common indications and techniques for delivering a fetal head was deep transverse arrest (45.7%) and Patwardhan (61.2%), respectively. Uterine incision extension was noted in 7 (6.6%), postpartum hemorrhage in 5 (4.7%), blood transfusion in 13 (12.4%) and neonatal intensive care unit (NICU) admissions in 29 (27.6%) cases. Compared with other methods, blood transfusion was more frequent when a push method was applied (p = 0.013). Neonates delivered by cesarean section after attempted assisted vaginal births had higher NICU admissions (p = 0.048) and lower Apgar scores (p = 0.005 and p 0.037 for 1 and 5 minutes, respectively) than other neonates. Conclusions: Second-stage cesarean section is technically challenging and usually accompanied by several maternal and neonatal risks. Appropriate skills and training for assisted vaginal birth under proper supervision should be encouraged. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to understand the complex relationship between maternal complications and women's characteristics in India. Methods: The present study builds structural equation modeling (SEM) using the data from the National Family Health Survey round 4 (2015–16) and includes 190, 898 women who had given their last birth during 5 years preceding the survey. Based on eight questions related to maternal complications, the SEM constructed two latent variables – complications during pregnancy (PREGCOMP) and delivery (DELCOMP). Results: Result shows that prolonged labor was highly prevalent (42%) among women, followed by vaginal bleeding (34%) and swelling in legs, body or face (32%). Women from affluent households (β = −0.02 for each‐middle, richer and richest quantile), with higher education (β = −0.02), timing when they received first ANC (β = −0.003) and women who received full ANC (β = −0.01) had a lower risk of PREGCOMP. However, consanguineous marriage (β = 0.01) was positively related to PREGCOMP. Further, women with PREGCOMP (β = 0.20), rural residents (β = 0.02), having exposure to mass media (β = 0.01), and who had facility delivery (β = 0.04) were at high risk of DELCOMP. Women with pregnancy complications are more likely to have delivery complications. [Correction added on 27 November, after first online publication: The statement "who received full antenatal care (ANC) (β = −0.05)" has been removed.] Conclusion: Socioeconomic and demographic factors significantly affect both the latent variables. This study concludes that the use of intensive healthcare services reduces health complications. The paper recommends early visits and full ANC checkups to reduce pregnancy complications. [ABSTRACT FROM AUTHOR]

Aim: to determine the rates of failed conversion of EA to surgical anaesthesia for patient and clinician information and benchmarking, and to develop an algorithmic approach for safe conversion of EA. Materials and Methods: A retrospective audit of parturients who had labour epidural analgesia (EA) at an advanced tertiary care institute for women and newborn health in south India. Information on EA, caesarean sections, conversion of EA, failure of regional anaesthesia, use of general anaesthesia, alternate techniques and supplemental medications were retrieved from electronic medical records. Results: Emergency cesarean section (CS) was performed for 4,259 (26.93%, 95% CI: 26.25, 27.63) of 15, 812 parturients that had EA at the study institute between Jan 2012 and December 2016. The EA was successful in 4,078 (95.75%, 95% CI: 95.11, 96.32) of these 4,259 women. Seventy three (1.71%, 95% CI: 1.37, 2.15) of the 4,259 women reported mild discomfort on the VAS for pain and required supplemental sedation for the emergency CS and 108 (2.53%, 95% CI: 2.11, 3.05) of the 4,259 women needed alternate techniques. The failure rate of EA was thus 4.25% (95% CI: 3.68, 4.89, n = 181) in this audit. Conclusions: The failure rates of EA at the study institute are well within the recommended standards of the RCA (Royal College of Anaesthesiologists – UK). This audit helped us to develop an algorithmic approach to further improve performance based on problems identified during the audit. [ABSTRACT FROM AUTHOR]

Introduction: Caesarean section is most common surgery performed worldwide, but increasing rate of caesarean birth has become an international concern of public health. According to WHO (World Health Organisation), rate of caesarean section should not be more than 15%. Aims and Objective: The main aim of this study was to classify the caesarean section according to Robsons's citeria and to identify the rising causes of caesarean section in our scenario. Material and Method: This was a cross sectional observational study and data was collected over a period of six months from every single patient, who underwent caesarean section in our hospital. Results: During the study period, total number of deliveries in this hospital was 519, out of which there were 300 caesarean section, thus, we have 57.80% rate of caesarean section. Maximum rate of caesarean section was in group 5 i.e. Multiparous with prior caesarean section, singleton, cephalic, ≥37 weeks followed by group 2 i.e. Nulliparous, singleton, cephalic, ≥37 weeks, induced labour or caesarean section before labour. Conclusions: This attempt of classifying the caesarean section by Robson's criteria helped to audit and identify the problem and to think about modifying the hospital protocols for reduction of rate of caesarean section. [ABSTRACT FROM AUTHOR]

Background: Indian women are more prone to first birth at a relatively younger age after marriage. Also, we do not have sufficient literature available that focuses on contraceptive use before first birth. The analysis of the present study was done using data from the fourth round of National Family Health Survey (2015-16), India. The objectives of the present study were to measure the levels and trends of contraceptive use before first birth among Indian ever married women, aged 15-34 years.Methods: The study includes 279,896 ever married women aged 15-34 years at the time of the NFHS-4 survey. To identify the socio-demographic determinants governing the pioneering study behavior, multivariable techniques have been used in the analysis. The statistical significance of the relationship between socio-demographic factors and contraceptive use prior to first birth was tested using a chi-squared test for association. Hosmer Lemeshow statistics and Nagelkerke R square have been used to check how well the logistic regression model fits the data. Map of India showing different zonal classification is made using the ArcGIS software version 10.3.Result: The trends of contraceptive usage show a decline in use before first birth and the various socio-demographic factors affecting the use of contraceptive before first birth are religion, caste, education, wealth index, media exposure, age at marriage and the zonal classifications.Conclusion: The noticeable result in this study is the comparative decline in contraceptive use by women in India before first birth in NFHS-4 with respect to previous NFHS done in India. The likelihood of using contraception before first birth is significantly affected by factors like place of residence, religion, caste, current age of women, age at marriage, education level of women, wealth index, media exposure and zonal classification. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate association between total IgE levels and wheezing in preschool children from India. Methods: Data were collected in a prospective birth cohort study related to wheezing till three years of age. Total IgE was measured at enrolment, at one year and two years of age and correlated with wheezing episodes. Results: A total of 310 (167 boys) children were enrolled. Total IgE levels increased with age (P<0.001). Overall, 101 (32.6%) children had 182 episodes of wheezing. The median (IQR) total IgE levels in children with wheezing and without wheezing were similar at one year [42.1 (12.7, 93.5) vs 41.9 (17.1, 96.7) kU/L; P=0.39] and two years of age [62.8 (32.4, 212.0) vs 75 (25.8, 173.0) kU/L, P=0.92). Conclusion: Total IgE levels increased with age and were not different in preschool children with and without wheezing. [ABSTRACT FROM AUTHOR]

Background: The BetterBirth trial tested the effect of a peer coaching program around the WHO Safe Childbirth Checklist for birth attendants in primary-level facilities in Uttar Pradesh, India on a composite measure of perinatal and maternal mortality and maternal morbidity. This study aimed to examine the adherence to essential birth practices between two different cadres of birth attendants-nurses and auxiliary nurse midwives (ANMs)-during and after a peer coaching intervention for the WHO Safe Childbirth Checklist.Methods: This is a secondary analysis of birth attendant characteristics, coaching visits, and behavior uptake during the BetterBirth trial through birth attendant surveys, coach observations, and independent observations. Descriptive statistics were calculated overall, and by staffing cadre (staff nurses and ANMs) for demographic characteristics. Logistic regression using the Pearson overdispersion correction (to account for clustering by site) was used to assess differences between staff nurses and ANMs in the intervention group during regular coaching (2-month time point) and 4 months after the coaching program ended (12-month time point).Results: Of the 570 birth attendants who responded to the survey in intervention and control arms, 474 were staff nurses (83.2%) and 96 were ANMs (16.8%). In the intervention arm, more staff nurses (240/260, 92.3%) received coaching at all pause points compared to ANMs (40/53, 75.5%). At baseline, adherence to practices was similar between ANMs and staff nurses (~ 30%). Overall percent adherence to essential birth practices among ANMs and nurses was highest at 2 months after intervention initiation, when frequent coaching visits occurred (68.1% and 64.1%, respectively, p = 0.76). Practice adherence tapered to 49.2% among ANMs and 56.1% among staff nurses at 12 months, which was 4 months after coaching had ended (p = 0.68).Conclusions: Overall, ANMs and nurses responded similarly to the coaching intervention with the greatest increase in percent adherence to essential birth practices after 2 months of coaching and subsequent decrease in adherence 4 months after coaching ended. While coaching is an effective strategy to support some aspects of birth attendant competency, the structure, content, and frequency of coaching may need to be customized according to the birth attendant training and competency.Trial Registration: ClinicalTrials.gov: NCT2148952; Universal Trial Number: U1111-1131-5647. [ABSTRACT FROM AUTHOR]

Despite an overall downward trend in child sex ratios in India, some of the most imbalanced districts in 2001 (fewer girls than boys) showed signs of becoming more balanced in 2011. This analysis looked in depth at these districts to better understand the nature of the improvement in the child sex ratio using two rounds of data from the Census of India from 2001 and 2011. Data were used from the 153 districts that showed improvement in their child sex ratio between 2001 and 2011. The improvement was decomposed into: (1) less sex-selective abortion and (2) improved girl compared with boy mortality. Most of the improvement in child sex ratios were shown to be due to reductions in sex-selective abortion, although this still made up the majority of the cause of imbalanced sex ratios in 2011. Child sex ratio improvement has been happening in both rural and urban areas of India, and there is evidence of stagnation in mortality decline for urban girls. [ABSTRACT FROM AUTHOR]

Background and aim: Thrombocytopenia in pregnancy varies from benign to severe with fetomaternal complications. We aimed to evaluate thrombocytopenia in pregnant Indian females in third trimester mainly during labor and delivery. Materials and methods: It was a prospective observational study done in a tertiary care teaching public hospital over 1 year. Consecutive 150 pregnant patients admitted to labor ward with thrombocytopenia were analyzed for etiology of thrombocytopenia, severity, mode of delivery, type of anesthesia, and fetomaternal complications. SPSS version 17 was used for the analysis. Results: Most common cause of thrombocytopenia was preeclampsia 50 (33.3%) and preeclampsia with hemolysis, elevated liver enzyme, and low platelet count syndrome (HELLP syndrome) 31 (20.7%) together followed by gestational 42 (28%). Infectious causes such as malaria, dengue, and leptospirosis were found in 19 patients (12.7%). Moderate to severe thrombocytopenia was seen in preeclampsia, preeclampsia with HELLP syndrome, and infectious etiology. Eleven patients (7.3%) developed antepartum hemorrhage (APH), 24 (16%) postpartum hemorrhage (PPH), 12 (8%) required ICU admission, and 3 (2%) mortalities were noted. Fifteen neonates (10%) needed ICU admission. Complications were observed in preeclampsia with HELLP syndrome (82%) and infectious causes (18%) and none in gestational. Sixty-eight patients underwent lower segment cesarean section (LSCS), among them 41 (27.3%) were given spinal anesthesia (SA) and none of them developed any neurological complications. Conclusion: Study widened the spectrum of causes for thrombocytopenia in pregnant patients. Preeclampsia with or without HELLP syndrome and vector-borne infections such as malaria, dengue, and leptospirosis were found to be very important causes of moderate to severe thrombocytopenia and were associated with complications. Spinal anesthesia is safe in parturients with mild thrombocytopenia. Awareness and vigilance about thrombocytopenia is vital to reduce maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background: A dedicated home birth team was established at a large teaching hospital in a deprived inner London borough. Aim: To increase the home birth rate in Tower Hamlets and offer continuity of carer to women opting for home birth. Methods: Data were collected on all 90 women receiving care by the team. Data, including demographics, care episodes and maternal and neonatal outcomes, were recorded and analysed using Microsoft Excel 2010. Findings: With a dedicated home birth team, the home birth rate in Tower Hamlets increased by 68% compared to the previous year, while still remaining a small proportion of all births in the borough. The overall transfer rate was 32.6%, in line with national figures. Outcomes for both mothers and babies were very good, with 89% of women who started their labour at home achieving a normal vaginal birth. Feedback was exceptionally positive, with 100% of women who provided feedback recommending the service. The women being referred and choosing homebirth were not demographically representative of the population of the borough. Conclusions: The provision of a dedicated homebirth team in Tower Hamlets has been a positive addition to the area's existing maternity services. More needs to be done to improve the visibility of the team in order to secure more referrals and increase the homebirth rate, especially among the Bengali and other ethnic minority populations, to enable equitable access to homebirth. [ABSTRACT FROM AUTHOR]

Introduction: Low Birth Weight (LBW) is an important decisive factor for most of the neonatal deaths, hence, Birth Weight (BW) is essential to identify immediately after birth for neonate survival and post-natal growth. The proper neonatal care and logistics are not available in every situation, especially in noninstitutional or home deliveries bear's difficulties to identify the relative risks of intra-uterine growth retardations and/or of newborns LBW. Aim: To identify the surrogate anthropometric measurements of Birth length (BL) and Head circumference (HC) as a proxy measure of newborns LBW and determine the operational cutoff points among the Bengali Hindu population of Kolkata, West Bengal, India. Materials and Methods: A total of 495 newborn BW data were collected from the hospital records from August 2016 to March 2017. Data were collected among Bengali Hindu mothers completed full gestational periods and delivered a normal singleton newborn. The data comprises of BW, BL and HC which were recorded using standard anthropometric procedures. The data were analysed in terms of descriptive statistics, correlation coefficients, linear and Binary logistic regression (BLR) and AUC-ROC analysis using SPSS (version, 16.0). Results: Out of 495 newborns included mean BW and LBW were 2.72±0.44 kg and 27.10%, respectively. The BW was correlated with BL (r=0.791) than HC (r=0.757) (p<0.001). Linear and BLR analysis showed that BL and HC exhibited significant influences on newborns BW (p<0.01). ROC-AUC analyses of BL (AUC=0.89, 95% CI 0.86-0.92) and HC (AUC=0.91, 95% CI 0.88-0.94) showed optimal surrogate indicators with LBW (p<0.01). The optimal cut-points for BL and HC to identify LBW newborns were <46.5 cm and <32.5 cm, respectively. Conclusion: BL is the best suitable anthropometric measure followed by HC to predict LBW newborns. These proxies anthropometric indicators would help to identify the relative risks LBW and neonates requiring intervention in field situations. [ABSTRACT FROM AUTHOR]

Objective: To develop a shortened, valid and reliable scale applicable across multiple settings for routine monitoring of person-centered maternity care (PCMC).Methods: Exploratory analysis was used to generate parsimonious versions of a 30-item PCMC scale in four datasets from cross-sectional surveys conducted between August 2016 and October 2017, involving women aged 15-49 years in Kenya, Ghana and India who had recently given birth. Analysis was informed by expert opinion via a separate online survey of global maternal and child health experts. Items retained in each dataset were compared, and those unique to a single setting removed. The remaining items were pooled and assessed for construct and criterion validity and reliability in each setting.Results: Thirteen items were retained for a potential multi-setting short PCMC scale, incorporating the domains of dignity and respect, communication and autonomy, and supportive care. Cronbach's alpha for the scale was >0.7 in each setting. Scores on the 13-item scale were correlated with the 30-item scale scores, and with global measures of care satisfaction in Kenya and India.Conclusion: Analysis yielded a 47% shorter PCMC scale, that showed promise for routine assessment of women's experience of care during childbirth across multiple settings. However, further validation is needed. [ABSTRACT FROM AUTHOR]

A deeply impacted foetal head in a second stage caesarean section is associated with an increased risk of maternal and neonatal complications. For the present study, we compared the maternal and neonatal outcomes during the use of the 'Push method' and of 'Patwardhan's method' for a foetal head delivery in a second-stage caesarean section. This was a retrospective observational study involving 298 women who underwent a second stage caesarean section with a foetal head at or below the level of their ischial spines and was conducted in a tertiary teaching hospital in South India. The rates of uterine incision extension and other maternal complications were similar in both methods (24.9% vs. 26.0%, p = .850). The rates of neonatal sepsis (2.3% vs. 9.2%) and admission to neonatal intensive care unit (36.7% vs. 60.0%) were higher when Patwardhan's method was used. Although the maternal complications were similar, the use of Patwardhan's method resulted in higher rates of neonatal complications compared to the Push method during a second stage caesarean section. Future randomised, controlled studies comparing these two methods are needed to confirm their safety and benefits, prior to its routine use in second stage caesarean sections. Impact statement What is already known on this subject? Use of a second-stage caesarean section increases the risk of maternal and neonatal complications. A deeply engaged foetal head, along with the stretching and thinning of the lower uterine segment predisposes to these complications. The recent literature mainly compares the complication rates of the Push method to a Reverse breech extraction, with only small studies reporting the use of Patwardhan's technique for the delivery of a deeply engaged foetal head. What do the results of this study add? This study suggests that the use of either the Push method or of Patwardhan's method results in similar maternal complications such as extension of a uterine incision or postpartum haemorrhage. But neonatal complications such as neonatal sepsis (2.3% vs. 9.2%) and admission to neonatal intensive care unit (36.7% vs. 60.0%) were higher when Patwardhan's method was used. What are the implications of these findings for clinical practice and/or further research? The extension of uterine incision is similar in both methods; however, the neonatal complications were noted to be higher in those delivered with Patwardhan's technique. A future, randomised controlled trial comparing these two techniques is required to confirm the findings, before either of the methods are used in routine practice. [ABSTRACT FROM AUTHOR]

The Multinomial Logit (MNL) model is popular, but a semi-parametric specification of its link/utility function has seldom been used in empirical applications. This is primarily because of the resource intensive nature of semi-parametric estimation. In this paper we propose and implement a parallel computation algorithm to estimate the semi-parametric kernel MNL model. This algorithm reduces model estimation time by a factor of 2–10, depending on the size of the dataset and the available resources for computation. These computational gains make the estimation of this model feasible for large datasets. Additionally, using a Monte Carlo study we show that the kernel MNL outperforms the traditional linear MNL model in terms of fit and predicted choice probabilities. We demonstrate how kernel-based specification can unearth important heterogeneities in the effect of covariates through an empirical exercise. We use data from a nationally representative household survey (N = 157,804) to analyze the factors associated with institutional births (as opposed to home births) in India. Our revealed-preference results indicate that maternal education, household assets, distance to formal health facility, and birth order play an essential role in determining birth location choice. Although the directions of impact are similar across both the linear and the kernel MNL specifications, there are significant differences in the marginal effects of different factors across the two models. These differences, which arise due to the flexibility afforded by the semi-parametric specification, potentially bring additional nuance to policy discussions. [ABSTRACT FROM AUTHOR]

Introduction: Newborn vaccination is an integral part of routine immunization program in India, but program implementation gaps exist. The focus of this article is to identify and describe an implementation strategy which could improve the newborn vaccination at the facility level. Materials and Methods: A situation analysis was conducted through a mixed-methods approach to identify the lacunae in the health system and the same was used to develop an implementation strategy to improve newborn vaccination coverage across the six priority states. Results: Issues in stewardship and human resource, vaccine-related stock-outs, and poor service delivery were some of the reasons for low facility-level vaccination coverage. After implementation of a health system–based strategy, the new born vaccination improved from 55% to 88% across 10 quarters of program implementation. Factors such as sensitization of stakeholders, vaccination on holidays, rigorous documentation, and supportive supervision of health staff were primary reasons for improvement in service delivery. Conclusion: Importance of newborn immunization at birth is well established. The results from six states prove that "health systems approach" as an implementation strategy is a viable tool to improve newborn immunization at birth. [ABSTRACT FROM AUTHOR]

Background of the Study: Excellent obstetrician and midwife must always be alert to detect any sign and symptoms of abnormal labor. Prolong labor presents a picture of mental anguish, physical morbidity and may need to emergency procedure and other surgical intervention1. The goal of this study is to use partogram to monitor labor, initiate uterine activity that is sufficient to produce cervical change and fetal descent while avoiding uterine hyperstimulation, hypostimulation and fetal distress and provide timely surgical intervention where required. Aim of the Study: The aim of the study is to assess the level of knowledge regarding partogram of nursing students in selected nursing colleges, Punjab. Material and Method: A quantitative research approach, descriptive study in which descriptive research design was used to conduct the research study. 60 nursing students of SINPMS, Badal were selected for the study with purposive sampling technique. A self structured knowledge questionnaire was used to assess the level of knowledge regarding partogram among nursing students. Result: the study depicted that out of 60 nursing students of SINPMS, Badal, 6(10%) have good level of knowledge followed by 41(68.3%) nursing students of SINPMS having average level of knowledge and the remaining 13(21.6%)nursing students of SINPMS having below average level of knowledge. So Average level of knowledge among Nursing students of SINPMS, Badal, Punjab. The overall mean 13.3 and SD is 6.82. Level of knowledge was significantly (p<0.5) not associated with age, gender, class, source of information. Conclusion: The study concluded that average level of knowledge among nursing students [ABSTRACT FROM AUTHOR]

Objectives: To investigate the nature and context of mistreatment during labour and childbirth at public and private sector maternity facilities in Uttar Pradesh, India. Methods: This study analyses mixed-methods data obtained through systematic clinical observations and open-ended comments recorded by the observers to describe care provision for 275 mothers and their newborns at 26 hospitals in three districts of Uttar Pradesh from 26 May to 8 July 2015. We conducted a bivariate descriptive analysis of the quantitative data and used a thematic approach to analyse qualitative data. Findings: All women in the study encountered at least one indicator of mistreatment. There was a high prevalence of not offering birthing position choice (92%) and routine manual exploration of the uterus (80%) in facilities in both sectors. Private sector facilities performed worse than the public sector for not allowing birth companions (p = 0.02) and for perineal shaving (p = < 0.001), whereas the public sector performed worse for not ensuring adequate privacy (p = < 0.001), not informing women prior to a vaginal examination (p = 0.01) and for physical violence (p = 0.04). Prepared comments by observers provide further contextual insights into the quantitative data, and additional themes of mistreatment, such as deficiencies in infection prevention, lack of analgesia for episiotomy, informal payments and poor hygiene standards at maternity facilities were identified. Conclusions: Mistreatment of women frequently occurs in both private and public sector facilities. This paper contributes to the literature on mistreatment of women during labour and childbirth at maternity facilities in India by articulating new constructs of overtreatment and under-treatment. There are five key implications of this study. First, a systematic and context-specific effort to measure mistreatment in public and private sector facilities in high burden states in India is required. Second, a training initiative to orient all maternity care personnel to the principles of respectful maternity care would be useful. Third, innovative mechanisms to improve accountability towards respectful maternity care are required. Fourth, participatory community and health system interventions to support respectful maternity care would be useful. Lastly, we note that there needs to be a long-term, sustained investment in health systems so that supportive and enabling work-environments are available to front- line health workers. [ABSTRACT FROM AUTHOR]

Objective: To determine the effectiveness and economic impact of two methods for induction of labour in hypertensive women, in low-resource settings.Design: Cost-consequence analysis of a previously reported multicentre, parallel, open-label randomised trial.Setting& Population: A total of 602 women with a live fetus, aged ≥18 years requiring delivery for pre-eclampsia or hypertension, in two public hospitals in Nagpur, India.Methods: We performed a formal economic evaluation alongside the INFORM clinical trial. Women were randomised to receive transcervical Foley catheterisation or oral misoprostol 25 mcg. Healthcare expenditure was calculated using a provider-side microcosting approach.Main Outcome Measures: Rates of vaginal this delivery within 24 hours of induction, healthcare expenditure per completed treatment episode.Results: Induction with oral misoprostol resulted in a (mean difference) $20.6USD reduction in healthcare expenditure [95% CI (-) $123.59 (-) $72.49], and improved achievement of vaginal delivery within 24 hours of induction, mean difference 10% [95% CI (-2 to 17.9%), P = 0.016]. Oxytocin administration time was reduced by 135.3 minutes [95% CI (84.4-186.2 minutes), P < 0.01] and caesarean sections by 9.1% [95% CI (1.1-17%), P = 0.025] for those receiving oral misoprostol. Following probabilistic sensitivity analysis, oral misoprostol was cost-saving in 63% of 5,000 bootstrap replications and achieved superior rates of vaginal delivery, delivery within 24 hours of induction and vaginal delivery within 24 hours of induction in 98.7%, 90.7%, and 99.4% of bootstrap simulations. Based on univariate threshold analysis, the unit price of oral misoprostol 25 mcg could feasibly increase 31-fold from $0.24 to $7.50 per 25 mcg tablet and remain cost-saving.Conclusion: Compared to Foley catheterisation for the induction of high-risk hypertensive women, oral misoprostol improves rates of vaginal delivery within 24 hours of induction and may also reduce costs. Additional research performed in other low-resource settings is required to determine their relative cost-effectiveness.Tweetable Abstract: Oral misoprostol less costly and more effective than Foley catheter for labour induction in hypertension. [ABSTRACT FROM AUTHOR]

Perinatal asphyxia refers to an impairment of the normal oxygenation during parturition and the ensuing adverse effects on the fetus/neonate. It is one of the major causes of early neonatal mortality in India. Among the institutional births, incidence is 5% and accounts for 24.3% of neonatal deaths. It is an insult to fetus or newborn due to lack of oxygen (hypoxia) or lack of perfusion (ischemia) to various organs of sufficient magnitude and duration. The aim of the study was to observe the urinary uric acid to creatnine ratio in patients with perinatal birth asphyxia in a hospital setting. It was concluded that UUA/Cr concentration increase considerably after birth asphyxia, and the increase is associated with severity of HIE with a poorer outcome. Hence, UUA/Cr might have an important role in diagnosing and predicting the outcome of perinatal asphyxia. [ABSTRACT FROM AUTHOR]

Background: Neonatal death remains a global challenge contributing to 45% of underfive deaths. With rising institutional delivery, to accelerate decline in neonatal mortality rate (NMR) improvement in the quality of perinatal care requires attention. Objectives: This implementation research targeted improving service delivery readiness for quality of newborn care at public health facilities in three districts of Uttar Pradesh, India, with high NMR. Materials and Methods: This before-after study assessed the facility readiness and quality of newborn services at 42 health facilities. The changes in 26 signal functions for routine and emergency obstetric and newborn care were tracked. Results: There was marked improvement in newborn service availability: skilled birth attendants (51%), resuscitation (30%), and kangaroo mother care (27%) at these facilities. A multifold rise in newborn resuscitation efforts and documentation (n = 4431 vs. n = 144 in preintervention period) with high success rate (98.6%) was observed. There was also improvement in obstetric care services including partograph use (31%) and active management of third stage of labor (46%). However, several infrastructural indicators (electricity, water supply, toilets, and sanitation) remained unchanged. Conclusion: Overall improvements were observed in the majority of the signal functions for perinatal care and newborn resuscitation efforts. There was a limited impact on the infrastructural and supervision components. [ABSTRACT FROM AUTHOR]