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Private Brazilian hospitals have one of the highest caesarean section (CS) rates in the world. Caesareans may have short- and long-term implications for the health of mothers and babies. The primary objective of this project was to assess the effects of an intrapartum quality improvement (QI) initiative on CS rates and on maternal/perinatal outcomes. A bundle targeted at internal healthcare providers (HCP) on-duty in the labour and delivery (LD) ward of a private Brazilian hospital was created in 2020 (first period) and implemented in 2021–2022 (second period). External HCPs managing their own private patients served as a control group. The bundle focused on improving intrapartum care in women without previous CS in spontaneous labour with single cephalic pregnancies at term (Robson groups 1 and 3). The bundle included a collaborative midwifery–obstetrician intrapartum model of care, a new LD ward medical coordinator, daily supportive supervision, updated LD guidelines and internal HCP refresher training on teamwork and intrapartum care. We analysed changes in outcomes between the two periods and the two HCP teams. The analyses included data on 24 414 women who gave birth (≥500 g) over a 30-month period.Among women managed by internal HCPs, there was a 32% relative decrease in Robson-1 CS rates (65.7% vs 44.6%, first vs second period, relative rate ratio (RRR)=0.68, p

Objective WHO recommends the use of the Robson’s ‘Ten Groups Classification’ for monitoring and assessing caesarean section (CS) rates. The aim of this study was to investigate the rates, indications and outcomes of CS using Robson classification in a tertiary hospital in Sierra Leone.Design Cross-sectional study.Setting Princess Christian Maternity Hospital (PCMH), Freetown, Sierra Leone.Participants All women who gave birth in PCMH from 1 October 2020 to 31 January 2021.Primary and secondary outcome measures Primary outcome: CS rate by Robson group. Secondary outcomes: indications for CS and the newborn outcomes for each Robson group.Results 1998 women gave birth during the study period and 992 CS were performed, with a CS rate of 49.6%. Perinatal mortality was 7.8% and maternal mortality accounted for 0.5%. Two-thirds of the women entered labour spontaneously and were considered at low risk (groups 1 and 3). CS rates in these groups were very high (43% group 1 and 33% group 3) with adverse outcomes (perinatal mortality, respectively, 4.1% and 6%). Dystocia was the leading indication for CS accounting for about two-thirds of the CS in groups 1 and 3. Almost all women with a previous CS underwent CS again (95%). The group of women who give birth before term (group 10) represents 5% of the population with high CS rate (50%) mainly because of emergency conditions.Conclusion Our data reveals a notably high CS rate, particularly among low-risk groups according to the Robson classification. Interpretation must consider PCMH as a referral hospital within an extremely low-resourced healthcare system, centralising all the complicated deliveries from a vast catchment area. Further research is required to assess the impact of referred obstetrical complications on the CS rate and the feasibility of implementing measures to improve the management of women with dystocia and previous CS.

Objective To predict birth weight at various potential gestational ages of delivery based on data routinely available at the first antenatal visit.Design Individual participant data meta-analysis.Data sources Individual participant data of four cohorts (237 228 pregnancies) from the International Prediction of Pregnancy Complications (IPPIC) network dataset.Eligibility criteria for selecting studies Studies in the IPPIC network were identified by searching major databases for studies reporting risk factors for adverse pregnancy outcomes, such as pre-eclampsia, fetal growth restriction, and stillbirth, from database inception to August 2019. Data of four IPPIC cohorts (237 228 pregnancies) from the US (National Institute of Child Health and Human Development, 2018; 233 483 pregnancies), UK (Allen et al, 2017; 1045 pregnancies), Norway (STORK Groruddalen research programme, 2010; 823 pregnancies), and Australia (Rumbold et al, 2006; 1877 pregnancies) were included in the development of the model.Results The IPPIC birth weight model was developed with random intercept regression models with backward elimination for variable selection. Internal-external cross validation was performed to assess the study specific and pooled performance of the model, reported as calibration slope, calibration-in-the-large, and observed versus expected average birth weight ratio. Meta-analysis showed that the apparent performance of the model had good calibration (calibration slope 0.99, 95% confidence interval (CI) 0.88 to 1.10; calibration-in-the-large 44.5 g, −18.4 to 107.3) with an observed versus expected average birth weight ratio of 1.02 (95% CI 0.97 to 1.07). The proportion of variation in birth weight explained by the model (R2) was 46.9% (range 32.7-56.1% in each cohort). On internal-external cross validation, the model showed good calibration and predictive performance when validated in three cohorts with a calibration slope of 0.90 (Allen cohort), 1.04 (STORK Groruddalen cohort), and 1.07 (Rumbold cohort), calibration-in-the-large of −22.3 g (Allen cohort), −33.42 (Rumbold cohort), and 86.4 g (STORK Groruddalen cohort), and observed versus expected ratio of 0.99 (Rumbold cohort), 1.00 (Allen cohort), and 1.03 (STORK Groruddalen cohort); respective pooled estimates were 1.00 (95% CI 0.78 to 1.23; calibration slope), 9.7 g (−154.3 to 173.8; calibration-in-the-large), and 1.00 (0.94 to 1.07; observed v expected ratio). The model predictions were more accurate (smaller mean square error) in the lower end of predicted birth weight, which is important in informing clinical decision making.Conclusions The IPPIC birth weight model allowed birth weight predictions for a range of possible gestational ages. The model explained about 50% of individual variation in birth weights, was well calibrated (especially in babies at high risk of fetal growth restriction and its complications), and showed promising performance in four different populations included in the individual participant data meta-analysis. Further research to examine the generalisability of performance in other countries, settings, and subgroups is required.Trial registration PROSPERO CRD42019135045

Introduction Assisted vaginal birth, also known as instrumental or operative vaginal birth, refers to a vaginal birth conducted with the help of an instrument such as forceps or a vacuum [...], Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth. L'acces aux soins obstetriques d'urgence, y compris l'accouchement vaginal assiste et la cesarienne, est essentiel pour ameliorer les effets de la maternite et de l'accouchement. Toutefois, bien que la proportion de cesariennes ait augmente ces dernieres decennies, le recours a l'accouchement vaginal assiste a diminue. C'est particulierement le cas dans les pays a revenu faible ou intermediaire, bien que l'accouchement vaginal assiste soit souvent moins risque qu'une cesarienne. Nous avons donc mene un processus en trois etapes afin d'imaginer un programme de recherche qui permettrait d'augmenter le recours a l'accouchement vaginal assiste ou de le reintroduire. Apres avoir realise une synthese des donnees probantes, qui a servi de base a une consultation avec des experts techniques qui ont propose un programme de recherche initial, nous avons sollicite et incorpore les avis des representantes des femmes pour ce programme. Ce processus nous a permis d'imaginer un programme de recherche complet, avec des sujets classes comme suit: (i) la necessite de comprendre la perception qu'ont les femmes de l'accouchement vaginal assiste et de fournir des informations appropriees et fiables; (ii) l'importance de la formation des prestataires de soins de sante en matiere de competences cliniques, mais aussi de respect dans les soins de sante, de communication efficace, de prise de decision partagee et de consentement eclaire; ou (iii) les obstacles a la mise en reuvre et a la durabilite et les facteurs qui les facilitent. Les reactions de femmes nous ont appris qu'il etait urgent de reconnaitre que l'accouchement, la naissance et le post-partum sont des processus humains intrinsequement physiologiques et dignes au cours desquels les interventions ne devraient etre mises en reuvre qu'en cas de necessite. La promotion et/ou la reintroduction de l'accouchement vaginal assiste dans les regions a faibles ressources necessitent que les pouvoirs publics, les decideurs politiques et les administrations d'hopitaux soutiennent les prestataires de soins de sante qualifies, qui pourront a leur tour soutenir respectueusement les femmes pendant l'accouchement. El acceso a la atencion obstetrica de emergencia, incluido el parto vaginal asistido y el parto por cesarea, es crucial para mejorar los resultados de la maternidad y el parto. No obstante, aunque el porcentaje de partos por cesarea ha aumentado en las ultimas decadas, el uso del parto vaginal asistido ha disminuido. Esto ocurre especialmente en los paises de ingresos bajos y medios, a pesar de que un parto vaginal asistido suele ser menos arriesgado que un parto por cesarea. Por lo tanto, llevamos a cabo un proceso de tres pasos para identificar un programa de investigacion necesario para aumentar el uso del parto vaginal asistido o volver a incorporarlo: tras realizar una sintesis de la evidencia, que sirvio de base para una consulta con expertos tecnicos que propusieron un programa de investigacion inicial, buscamos e integramos las opiniones de las representantes de las mujeres sobre este programa. Este proceso nos ha permitido identificar un programa de investigacion exhaustivo, con temas categorizados como: (i) la necesidad de comprender las percepciones de las mujeres sobre el parto vaginal asistido, y proporcionar informacion adecuada y fiable; (ii) la importancia de formar a los profesionales sanitarios en habilidades clinicas, pero tambien en atencion respetuosa, comunicacion efectiva, toma de decisiones compartida y consentimiento informado; o (iii) las barreras y los facilitadores de la implementacion y la sostenibilidad. A partir de las opiniones de las mujeres, nos enteramos de la urgente necesidad de reconocer las experiencias del parto, el alumbramiento y el posparto como procesos humanos inherentemente fisiologicos y dignos, en los que las intervenciones solo deben aplicarse si son necesarias. La promocion o la reincoporacion del parto vaginal asistido en regiones de escasos recursos exige que los gobiernos, los responsables de formular politicas y los administradores de hospitales apoyen a los profesionales sanitarios capacitados que, a su vez, pueden ayudar a las mujeres en el trabajo de parto y el alumbramiento de manera respetuosa. [phrase omitted]

Introduction Caesarean section (CS) rates in Indonesia are increasing rapidly. Understanding women’s preferences about mode of birth is important to help contextualise these rising rates and can help develop interventions to optimise CS. This study aimed to explore Indonesian women’s preferences and decision-making about mode of birth, and how their preferences may change throughout pregnancy and birth.Methods We conducted a longitudinal qualitative study using in-depth interviews with 28 women accessing private and public health facilities in Jakarta, the region with the highest CS rates. Interviews were conducted two times: during the woman’s third trimester of pregnancy and in the postpartum period, between October 2022 and March 2023. We used a reflexive thematic approach for analysis.Results We generated three themes: (1) preferences about the mode of birth, (2) decision-making about the mode of birth and (3) regrets about the actual mode of birth. Most women preferred vaginal birth. However, they were influenced by advertisements promoting enhanced recovery after CS (ERACS) as an ‘advanced technique’ of CS, promising a comfortable, painless and faster recovery birth. This messaging influenced women to perceive CS as equivalent or even superior to vaginal birth. Where women’s preferences for mode of birth shifted around the time of birth, this was primarily due to the obstetricians’ discretion. Women felt they did not receive adequate information from obstetricians on the benefits and risks of CS and vaginal birth and felt disappointed when their actual mode of birth was not aligned with their preferences.Conclusion Our study shows that despite rising CS rates, Indonesian women prefer vaginal birth. This highlights the need for better communication strategies and evidence-based information from healthcare providers. Given the rising popularity of ERACS, more work is urgently needed to standardise and regulate its use.

BACKGROUND: As an evidence-based intervention to prevent maternal and neonatal morbidity and mortality, cesarean birth at rates of under 2%, which is the case in rural Southwest Ethiopia, is an unacceptable public health problem and represents an important disparity in the use of this life-saving treatment compared to more developed regions. The objective of this study is to explore an innovative clinical solution (a mobile cesarean birth center) to low cesarean birth rates resulting from the Three Delays to emergency obstetric care in isolated and underserved regions of Ethiopia, and the world. METHODS: We will use mixed but primarily qualitative methods to explore and prepare the mobile cesarean birth center for subsequent implementation in communities in Bench Sheko and West Omo Zones. This will involve interviews and focus groups with key stakeholders and retreat settings for user-centered design activities. We will present stakeholders with a prototype surgical truck that will help them conceive of the cesarean birth center concept and discuss implementation issues related to staffing, supplies, referral patterns, pre- and post-operative care, and relationship to locations for vaginal birth. DISCUSSION: Completion of our study aims will allow us to describe participants perceptions about barriers and facilitators to cesarean birth and their attitudes regarding the appropriateness, acceptability, and feasibility of a mobile cesarean birth center as a solution. It will also result in a specific, measurable, attainable, relevant, and timely (SMART) implementation blueprint(s), with implementation strategies defined, as well as recruitment plans identified. This will include the development of a logic model and process map, a timeline for implementation with strategies selected that will guide implementation, and additional adaptation/adjustment of the mobile center to ensure fit for the communities of interest. TRIAL REGISTRATION: There is no healthcare intervention on human participants occurring as part of this research, so the study has not been registered.

Objective To improve understanding of the drivers of the increased caesarean section (CS) rate in Romania and to identify interventions to reverse this trend, as well as barriers and facilitators.Design A formative research study was conducted in Romania between November 2019 and February 2020 by means of in-depth interviews and focus-group discussions. Romanian decision-makers and high-level obstetricians preselected seven non-clinical interventions for consideration. Thematic content analysis was carried out.Participants 88 women and 26 healthcare providers and administrators.Settings Counties with higher and lower CS rates were selected for this research—namely Argeș, Bistrița-Năsăud, Brașov, Ialomița, Iași, Ilfov, Dolj and the capital city of București (Bucharest).Results Women wanted information, education and support. Obstetricians feared malpractice lawsuits; this was identified as a key reason for performing CSs. Most obstetrics and gynaecology physicians would oppose policies of mandatory second opinions, financial measures to equalise payments for vaginal and CS births and goal setting for CS rates. In-service training was identified as a need by obstetricians, midwives and nurses. In addition, relevant structural constraints were identified: perceived lower quality of care for vaginal birth, a lack of obstetricians with expertise in managing complicated vaginal births, a lack of anaesthesiologists and midwives, and family doctors not providing antenatal care. Finally, women expressed the need to ensure their rights to dignified and respectful healthcare through pregnancy and childbirth.Conclusion Consideration of the views, values and preferences of all stakeholders in a multifaceted action tailored to Romanian determinants is critical to address relevant determinants to reduce unnecessary CSs. Further studies should assess the effect of multifaceted interventions.

Objectives Daily calcium supplements are recommended for pregnant women from 20 weeks’ gestation to prevent pre-eclampsia in populations with low dietary calcium intake. We aimed to improve understanding of barriers and facilitators for calcium supplement intake during pregnancy to prevent pre-eclampsia.Design Mixed-method systematic review, with confidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative research approach.Data sources MEDLINE and EMBASE (via Ovid), CINAHL and Global Health (via EBSCO) and grey literature databases were searched up to 17 September 2022.Eligibility criteria We included primary qualitative, quantitative and mixed-methods studies reporting implementation or use of calcium supplements during pregnancy, excluding calcium fortification and non-primary studies. No restrictions were imposed on settings, language or publication date.Data extraction and synthesis Two independent reviewers extracted data and assessed risk of bias. We analysed the qualitative data using thematic synthesis, and quantitative findings were thematically mapped to qualitative findings. We then mapped the results to behavioural change frameworks to identify barriers and facilitators.Results Eighteen reports from nine studies were included in this review. Women reported barriers to consuming calcium supplements included limited knowledge about calcium supplements and pre-eclampsia, fears and experiences of side effects, varying preferences for tablets, dosing, working schedules, being away from home and taking other supplements. Receiving information regarding pre-eclampsia and safety of calcium supplement use from reliable sources, alternative dosing options, supplement reminders, early antenatal care, free supplements and support from families and communities were reported as facilitators. Healthcare providers felt that consistent messaging about benefits and risks of calcium, training, and ensuring adequate staffing and calcium supply is available would be able to help them in promoting calcium.Conclusion Relevant stakeholders should consider the identified barriers and facilitators when formulating interventions and policies on calcium supplement use. These review findings can inform implementation to ensure effective and equitable provision and scale-up of calcium interventions.PROSPERO registration number CRD42021239143.

Objectives To synthesise evidence on the perceptions of healthcare providers (HCPs) about the quality of oxytocin and misoprostol available in their settings, and their actions as a result of these perceptions.Design Mixed-methods systematic review.Eligibility criteria We included quantitative and qualitative studies reporting HCPs’ perceptions about oxytocin or misoprostol quality.Data sources We searched CINAHL, Cochrane Library, Ebscohost, Embase, PubMed, Global Index Medicus, Portal regional BVS, PsycNET, Scopus and Web of Science from inception to 31 March 2022 and grey literature.Risk of bias We used the Center for Evidence-Based Management critical appraisal tool for surveys. For qualitative studies, we used the Critical Appraisal Skills Programme tool.Data extraction and synthesis Two independent reviewers performed study selection, data extraction and quality assessment. We conducted separate quantitative and qualitative syntheses and integrated the evidence into a narrative synthesis (convergent segregated review design).Results We included five (three quantitative and two qualitative) studies, of moderate or high quality, conducted in low-income and middle-income countries (LMICs). In the three quantitative studies (N=7065 participants), 8.2–21.3% of HCPs had experienced problems due to known/suspected low-quality oxytocin and 3.3% due to low-quality misoprostol. In the two qualitative studies, perception of oxytocin quality varied. In quantitative studies, when confronted with suspected/known low-quality oxytocin, 29–78% of HCPs would inform a supervisor, 62% would document this in writing, 45–54% would change to another drug and 5–37% would double the dose of oxytocin. Qualitative evidence suggests that many HCPs do not formally report suspected low-quality oxytocin or misoprostol, and use higher doses or additional uterotonics.Conclusions A proportion of HCPs from LMICs perceive oxytocin to be of low quality. There is very limited evidence on their perceptions about misoprostol. Many HCPs do not report suspected low-quality uterotonics but change to another medicine or double the dose of oxytocin.PROSPERO registration number CRD42022323812.

IntroductionShort interpregnancy interval (IPI) has been linked to adverse pregnancy outcomes. WHO recommends waiting at least 2 years after a live birth and 6 months after miscarriage or induced termination before conception of another pregnancy. The evidence underpinning these recommendations largely relies on data from low/middle-income countries. Furthermore, recent epidemiological investigations have suggested that these studies may overestimate the effects of IPI due to residual confounding. Future investigations of IPI effects in high-income countries drawing from large, population-based data sources are needed to inform IPI recommendations. We aim to assess the impact of IPIs on maternal and child health outcomes in high-income countries.Methods and analysisThis international longitudinal retrospective cohort study will include more than 18 million pregnancies, making it the largest study to investigate IPI in high-income countries. Population-based data from Australia, Finland, Norway and USA will be used. Birth records in each country will be used to identify consecutive pregnancies. Exact dates of birth and clinical best estimates of gestational length will be used to estimate IPI. Administrative birth and health data sources with >99% coverage in each country will be used to identify maternal sociodemographics, pregnancy complications, details of labour and delivery, birth and child health information. We will use matched and unmatched regression models to investigate the impact of IPI on maternal and infant outcomes, and conduct meta-analysis to pool results across countries.Ethics and disseminationEthics boards at participating sites approved this research (approval was not required in Finland). Findings will be published in peer-reviewed journals and presented at international conferences, and will inform recommendations for optimal IPI in high-income countries. Findings will provide important information for women and families planning future pregnancies and for clinicians providing prenatal care and giving guidance on family planning.

Introduction Low dietary calcium intake is a risk factor for pre-eclampsia, a major contributor to maternal and perinatal mortality and morbidity worldwide. Calcium supplementation can prevent pre-eclampsia in women with low dietary calcium. However, the optimal dose and timing of calcium supplementation are not known. We plan to undertake an individual participant data (IPD) meta-analysis of randomised trials to determine the effects of various calcium supplementation regimens in preventing pre-eclampsia and its complications and rank these by effectiveness. We also aim to evaluate the cost-effectiveness of calcium supplementation to prevent pre-eclampsia.Methods and analysis We will identify randomised trials on calcium supplementation before and during pregnancy by searching major electronic databases including Embase, CINAHL, MEDLINE, CENTRAL, PubMed, Scopus, AMED, LILACS, POPLINE, AIM, IMSEAR, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform, without language restrictions, from inception to February 2022. Primary researchers of the identified trials will be invited to join the International Calcium in Pregnancy Collaborative Network and share their IPD. We will check each study’s IPD for consistency with the original authors before standardising and harmonising the data. We will perform a series of one-stage and two-stage IPD random-effect meta-analyses to obtain the summary intervention effects on pre-eclampsia with 95% CIs and summary treatment–covariate interactions (maternal risk status, dietary intake, timing of intervention, daily dose of calcium prescribed and total intake of calcium). Heterogeneity will be summarised using tau2, I2 and 95% prediction intervals for effect in a new study. Sensitivity analysis to explore robustness of statistical and clinical assumptions will be carried out. Minor study effects (potential publication bias) will be investigated using funnel plots. A decision analytical model for use in low-income and middle-income countries will assess the cost-effectiveness of calcium supplementation to prevent pre-eclampsia.Ethics and dissemination No ethical approvals are required. We will store the data in a secure repository in an anonymised format. The results will be published in peer-reviewed journals.PROSPERO registration number CRD42021231276.

Objective To explore the behavioural drivers of fear of litigation among healthcare providers influencing caesarean section (CS) rates.Design Scoping review.Data sources We searched MEDLINE, Scopus and WHO Global Index (1 January 2001 to 9 March 2022).Data extraction and synthesis Data were extracted using a form specifically designed for this review and we conducted content analysis using textual coding for relevant themes. We used the WHO principles for the adoption of a behavioural science perspective in public health developed by the WHO Technical Advisory Group for Behavioural Sciences and Insights to organise and analyse the findings. We used a narrative approach to summarise the findings.Results We screened 2968 citations and 56 were included. Reviewed articles did not use a standard measure of influence of fear of litigation on provider’s behaviour. None of the studies used a clear theoretical framework to discuss the behavioural drivers of fear of litigation. We identified 12 drivers under the three domains of the WHO principles: (1) cognitive drivers: availability bias, ambiguity aversion, relative risk bias, commission bias and loss aversion bias; (2) social and cultural drivers: patient pressure, social norms and blame culture and (3) environmental drivers: legal, insurance, medical and professional, and media. Cognitive biases were the most discussed drivers of fear of litigation, followed by legal environment and patient pressure.Conclusions Despite the lack of consensus on a definition or measurement, we found that fear of litigation as a driver for rising CS rates results from a complex interaction between cognitive, social and environmental drivers. Many of our findings were transferable across geographical and practice settings. Behavioural interventions that consider these drivers are crucial to address the fear of litigation as part of strategies to reduce CS.

Objective To synthesise the evidence from studies that implemented interventions to increase/reintroduce the use of assisted vaginal births (AVB).Design Systematic review.Eligibility criteria We included experimental, semi-experimental and observational studies that reported any intervention to reintroduce/increase AVB use.Data sources We searched PubMed, EMBASE, CINAHL, LILACS, Scopus, Cochrane, WHO Library, Web of Science, ClinicalTrials.gov and WHO.int/ictrp through September 2021.Risk of bias For trials, we used the Cochrane Effective Practice and Organisation of Care tool; for other designs we used Risk of Bias for Non-Randomised Studies of Interventions.Data extraction and synthesis Due to heterogeneity in interventions, we did not conduct meta-analyses. We present data descriptively, grouping studies according to settings: high-income countries (HICs) or low/middle-income countries (LMICs). We classified direction of intervention effects as (a) statistically significant increase or decrease, (b) no statistically significant change or (c) statistical significance not reported in primary study. We provide qualitative syntheses of the main barriers and enablers for success of the intervention.Results We included 16 studies (10 from LMICs), mostly of low or moderate methodological quality, which described interventions with various components (eg, didactic sessions, simulation, hands-on training, guidelines, audit/feedback). All HICs studies described isolated initiatives to increase AVB use; 9/10 LMIC studies tested initiatives to increase AVB use as part of larger multicomponent interventions to improve maternal/perinatal healthcare. No study assessed women’s views or designed interventions using behavioural theories. Overall, interventions were less successful in LMICs than in HICs. Increase in AVB use was not associated with significant increase in adverse maternal or perinatal outcomes. The main barriers to the successful implementation of the initiatives were related to staff and hospital environment.Conclusions There is insufficient evidence to indicate which intervention, or combination of interventions, is more effective to safely increase AVB use. More research is needed, especially in LMICs, including studies that design interventions taking into account theories of behaviour change.PROSPERO registration number CRD42020215224.

ABSTRACT Understanding the genetic diversity and mechanisms underlying genetic variation in pathogen populations is crucial to the development of effective control strategies. We investigated the genetic diversity and reproductive biology of Colletotrichum graminicola isolates which infect maize by sequencing the genomes of 108 isolates collected from 14 countries using restriction site-associated DNA sequencing (RAD-seq) and whole-genome sequencing (WGS). Clustering analyses based on single-nucleotide polymorphisms revealed three genetic groups delimited by continental origin, compatible with short-dispersal of the pathogen and geographic subdivision. Intra- and intercontinental migration was observed between Europe and South America, likely associated with the movement of contaminated germplasm. Low clonality, evidence of genetic recombination, and high phenotypic diversity were detected. We show evidence that, although it is rare (possibly due to losses of sexual reproduction- and meiosis-associated genes) C. graminicola can undergo sexual recombination. Our results support the hypotheses that intra- and intercontinental pathogen migration and genetic recombination have great impacts on the C. graminicola population structure. IMPORTANCE Plant pathogens cause significant reductions in yield and crop quality and cause enormous economic losses worldwide. Reducing these losses provides an obvious strategy to increase food production without further degrading natural ecosystems; however, this requires knowledge of the biology and evolution of the pathogens in agroecosystems. We employed a population genomics approach to investigate the genetic diversity and reproductive biology of the maize anthracnose pathogen (Colletotrichum graminicola) in 14 countries. We found that the populations are correlated with their geographical origin and that migration between countries is ongoing, possibly caused by the movement of infected plant material. This result has direct implications for disease management because migration can cause the movement of more virulent and/or fungicide-resistant genotypes. We conclude that genetic recombination is frequent (in contrast to the traditional view of C. graminicola being mainly asexual), which strongly impacts control measures and breeding programs aimed at controlling this disease.

Abstract Background As an evidence-based intervention to prevent maternal and neonatal morbidity and mortality, cesarean birth at rates of under 2%, which is the case in rural Southwest Ethiopia, is an unacceptable public health problem and represents an important disparity in the use of this life-saving treatment compared to more developed regions. The objective of this study is to explore an innovative clinical solution (a mobile cesarean birth center) to low cesarean birth rates resulting from the Three Delays to emergency obstetric care in isolated and underserved regions of Ethiopia, and the world. Methods We will use mixed but primarily qualitative methods to explore and prepare the mobile cesarean birth center for subsequent implementation in communities in Bench Sheko and West Omo Zones. This will involve interviews and focus groups with key stakeholders and retreat settings for user-centered design activities. We will present stakeholders with a prototype surgical truck that will help them conceive of the cesarean birth center concept and discuss implementation issues related to staffing, supplies, referral patterns, pre- and post-operative care, and relationship to locations for vaginal birth. Discussion Completion of our study aims will allow us to describe participants’ perceptions about barriers and facilitators to cesarean birth and their attitudes regarding the appropriateness, acceptability, and feasibility of a mobile cesarean birth center as a solution. It will also result in a specific, measurable, attainable, relevant, and timely (SMART) implementation blueprint(s), with implementation strategies defined, as well as recruitment plans identified. This will include the development of a logic model and process map, a timeline for implementation with strategies selected that will guide implementation, and additional adaptation/adjustment of the mobile center to ensure fit for the communities of interest. Trial registration There is no healthcare intervention on human participants occurring as part of this research, so the study has not been registered.

Objectives To examine hospital variation in crude and risk-adjusted rates of intrapartum-related perinatal mortality among caesarean births.Design Secondary analysis of data from the DECIDE (DECIsion for caesarean DElivery) cluster randomised trial postintervention phase.Setting 21 district and regional hospitals in Burkina Faso.Participants All 5134 women giving birth by caesarean section in a 6-month period in 2016.Primary outcome measure Intrapartum-related perinatal mortality (fresh stillbirth or neonatal death within 24 hours of birth).Results Almost 1 in 10 of 5134 women giving birth by caesarean experienced an intrapartum-related perinatal death. Crude mortality rates varied substantially from 21 to 189 per 1000 between hospitals. Variation was markedly reduced after adjusting for case mix differences (the median OR decreased from 1.9 (95% CI 1.5 to 2.5) to 1.3 (95% CI 1.2 to 1.7)). However, higher and more variable adjusted mortality persisted among hospitals performing fewer caesareans per month. Additionally, adjusting for caesarean care components did not further reduce variation (median OR=1.4 (95% CI 1.2 to 1.8)).Conclusions There is a high burden of intrapartum-related perinatal deaths among caesarean births in Burkina Faso and sub-Saharan Africa more widely. Variation in adjusted mortality rates indicates likely differences in quality of caesarean care between hospitals, particularly lower volume hospitals. Improving access to and quality of emergency obstetric and newborn care is an important priority for improving survival of babies at birth.Trial registration number ISRCTN48510263.

Plain language summary During the late stages of childbirth, complications can occur which require rapid birth of the baby. This can be facilitated with instruments (usually forceps or a suction cup) or by surgery (caesarean section). In some circumstances, instrumental birth (also termed assisted vaginal delivery, AVD) may be a better option than caesarean section. AVD requires practitioners to develop skills, competence and expertise in the procedure. Our aim for this review was to examine practitioners’, funders’ and policy makers’ views about competence and expertise in AVD, how they can best gain this, the barriers and facilitators to implementing training packages, and their views, opinions and perspectives of their training. We included 27 studies (published 1985–2020), mostly from high-income countries. We had moderate confidence on one findings statement, with the rest assessed with low confidence. We found that practitioners valued extra training in AVD, observing others using the different instruments, and opportunities for clinical supervision, mentorship to gain experience, competence and expertise. We also found that, from the practitioners’ perspective, competence encompasses a number of inter-related skill sets; non-technical skills (e.g. effective communication with the labouring woman), broad clinical skills (e.g. capacity to assess the whole clinical picture) and technical instrumental skills (e.g. correct application of a vacuum cup to the fetal head, or capacity to turn the baby so it is in the right position). Practitioners also identified a number of barriers and facilitators that supported (or did not support) their training needs and development.

Optimizing caesarean section use is a global health priority, given the maternal and perinatal morbidity and mortality associated with caesarean underuse and overuse. (1,2) Monitoring caesarean section rates is important [...]

Abstract Background Cesarean section (CS) rates have been increasing globally. Iran has one of the highest CS rates in the world (47.9%). This review was conducted to assess the prevalence of and reasons for women’s, family members’, and health professionals’ preferences for CS in Iran. Methods and findings In this mixed-methods systematic review, we searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, Google scholar; as well as Iranian scientific databases including SID, and Magiran from 1 January 1990 to 8th October 2019. Primary quantitative, qualitative, and mixed-methods studies that had been conducted in Iran with Persian or English languages were included. Meta-analysis of quantitative studies was conducted by extracting data from 65 cross-sectional, longitudinal, and baseline measurements of interventional studies. For meta-synthesis, we used 26 qualitative studies with designs such as ethnography, phenomenology, case studies, and grounded theory. The Review Manager Version 5.3 and the Comprehensive Meta-Analysis (CMA) software were used for meta-analysis and meta-regression analysis. Results showed that 5.46% of nulliparous women (95% CI 5.38–5.50%; χ2 = 1117.39; df = 28 [p

Resumen Introducción Aun cuando la cesárea es una intervención que puede ser esencial para salvar la vida de una mujer y su hijo, el crecimiento excesivo de su uso es un problema global. El propósito de esta investigación formativa es recolectar información sobre las instituciones, profesionales de la salud y mujeres acerca del uso de la cesárea en la Argentina. Este artículo describe la metodología del estudio, las características de los hospitales y el perfil de los participantes. Metodología Esta investigación formativa usa un diseño mixto aplicado en siete provincias del país. Los criterios de elegibilidad para los hospitales son: (a) uso del Sistema Informático Perinatal, (b) tasa de cesáreas mayor al 27% en 2016, y (c) ≥ 1000 partos por año. Se usarán técnicas cualitativas y cuantitativas para la recolección de datos y el análisis. Los principales temas a indagar son los determinantes del uso de la cesárea, las intervenciones para optimizar su uso y, en el caso de las mujeres, sus preferencias sobre el modo de parto. Discusión Se espera que los resultados den lugar a un diagnóstico de situación que permita una implementación de las intervenciones propuesas por la OMS para optimizar el uso de la cesárea más ajustada al contexto. Registro del estudio IS002316

Introduction WHO recommends that all women have the option to have a companion of their choice throughout labour and childbirth. Despite clear benefits of labour companionship, including better birth experiences and reduced caesarean section, labour companionship is not universally implemented. In Thailand, there are no policies for public hospitals to support companionship. This study aims to understand factors affecting implementation of labour companionship in Thailand.Methods This is formative qualitative research to inform the ‘Appropriate use of caesarean section through QUALIty DECision-making by women and providers’ (QUALI-DEC) study, to design, adapt and implement a strategy to optimise use of caesarean section. We use in-depth interviews and readiness assessments to explore perceptions of healthcare providers, women and potential companions about labour companionship in eight Thai public hospitals. Qualitative data were analysed using thematic analysis, and narrative summaries of the readiness assessment were generated. Factors potentially affecting implementation were mapped to the Capability, Opportunity, and Motivation behaviour change model (COM-B).Results 127 qualitative interviews and eight readiness assessments are included in this analysis. The qualitative findings were grouped in four themes: benefits of labour companions, roles of labour companions, training for labour companions and factors affecting implementation. The findings showed that healthcare providers, women and their relatives all had positive attitudes towards having labour companions. The readiness assessment highlighted implementation challenges related to training the companion, physical space constraints, overcrowding and facility policies, reiterated by the qualitative reports.Discussion If labour companions are well-trained on how to best support women, help them to manage pain and engage with healthcare teams, it may be a feasible intervention to implement in Thailand. However, key barriers to introducing labour companionship must be addressed to maximise the likelihood of success mainly related to training and space. These findings will be integrated into the QUALI-DEC implementation strategies.