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Purpose: To analyze the effects of 1 or more patient-reported allergies on clinical outcomes, in particular graft failure rate, and patient-reported outcomes (PROs) following osteochondral allograft transplantation (OCA) of the knee. Methods: Retrospective review of patients who underwent knee OCA from August 2010 to May 2021 with a minimum of 2-year follow-up. Patients were initially divided into 2 cohorts: those with at least 1 allergy and those without any allergies. Clinical outcomes assessed included graft failure, reoperation rates, deep vein thrombosis/pulmonary embolism, and manipulation under anesthesia/lysis of adhesions (MUA/LOA). PROs assessed, including the visual analog scale (VAS) for pain and satisfaction, the Knee injury and Osteoarthritis Outcome Score (KOOS), and return to sport rates, were compared. Results: In total, 285 patients were included with a mean clinical follow-up of 4.8 ± 2.0 years. The allergy cohort had a significantly higher rate of graft failure (P = .008). In a regression analysis controlling for confounding variables, graft failure remained significantly associated with the presence of medication allergies (odds ratio [OR], 3.631; 95% CI, 1.139-11.577; P = .029). Furthermore, an increasing number of allergies were associated with an increased rate of graft failure (OR, 1.644; 95% CI, 1.074-2.515; P = .022). There was no difference in rate of reoperation, complications, infection, and MUA/LOA. Of the 100 patients who completed PROs, there was no difference in VAS satisfaction, pain, and any of the KOOS outcome scores or return to sport. Conclusions: The presence of 1 or more patient-reported allergies was shown to be significantly associated with OCA graft failure. Furthermore, an increasing number of patient-reported allergies were associated with a higher rate of graft failure. However, there were no significant differences in VAS satisfaction or pain, KOOS symptom, quality of life, pain, or return to sport in patients with at least 1 patient-reported allergy and those without allergies. Level of Evidence: Level III, retrospective cohort study.

Objective: To investigate the utility of simultaneous multi-catheter cryotherapy for the treatment of APs that were previously resistant to standard radiofrequency (RF) catheter ablation. Background: Catheter ablation is established in the treatment of accessory pathways (AP), with high rates of permanent procedural success with a single attempt. However, there are still instances of acute procedural failure and AP recurrences with standard RF and cryotherapy methods. Methods: Seven consecutive cases of pre-excitation syndromes with prior failed RF catheter ablation had the novel treatment. Cryotherapy was delivered using two 8 mm tip focal cryoablation catheters (Freezor® Max, Medtronic, Minneapolis, Minnesota, USA). Results: Accessory pathway localisation was septal in 5 cases, left posterolateral in 1, right lateral in 1. In all cases, ablation of the AP was acutely successful with no procedural complications. Median procedure and fluoroscopy durations were 199 and 35 min, sequentially. Median Procedure duration fell significantly in the second half of series (174 min) compared to the first half (233 min, P = 0.05). One patient had evidence of a recurring AP conduction with pre-excitation at 5-week follow up. After a median follow up of 66.8+-6.5 months, 6 out of 7 patients remained asymptomatic and free of pre-excitation. Conclusion: Simultaneous multi-catheter cryotherapy is feasible, safe and can provide definitive cure of accessory pathways that were previously resistant to standard radiofrequency ablation. Further study is required in the assessment of this novel form of advanced cryotherapy to treat complex and resistant arrhythmias.

Background: Diabetes mellitus is a chronic, progressive disorder that causes a variety of health problems. Adherence to medication is a major factor in the treatment outcome. The goal of this study is to translate and test the psychometric features of the Kurdish version of the Morisky Medication Adherence Scale (MMAS-8) among type 2 diabetic patients. Methods: The research used a cross-sectional approach. The researchers looked at a convenient sample of diabetic Kurdish individuals. MMAS-8 was translated into Kurdish using a normal “forward–backward” technique. It was then tested on 307 type 2 diabetic outpatients in a convenience sample. Internal consistency was checked for reliability. Convergent and known group validity were used to confirm validity. For the authentic statistical analysis, the Statistical Package for Social Sciences (SPSS) version 20 was used. Results: According to MMAS-8, 20 patients (6.5%) had a high adherence rate, 66 (21.5%) had a medium adherence rate, and 221 (72%) had a low adherence rate. There was no significant link between adherence score and gender (P = 0.055), illness duration (P = 0.251), or educational level (P = 0.12). There was a significant connection between adherence and HBA1C (P 0.001). Conclusion: The results of this validation study show that the Kurdish version of the MMAS-8 is a reliable and valid measure of medication adherence that may now be used. non-adherent. Developing patients’ treatment adherence will improve treatment managements and control.

Introduction: The association between oxidative Deoxy Ribonucleic Acid (DNA) damage and diabetes is well established. Increased glucose levels can stimulate free radical production. However, data regarding DNA damage in type 2 Diabetes Mellitus (DM) patients and healthy individuals are controversial and scarce in Iraq. Aim: To assess the DNA damage among patients with type 2 Diabetes Mellitus (DM) and healthy individuals and to analyse its relationship with oxidative stress biomarkers. Materials and Methods: This case-control study was conducted at the Duhok Diabetes Center, Duhok, Kurdistan Region, Iraq, from September 2016 to March 2018. In this study, biomarkers of both oxidative stress and DNA damage including Total Antioxidant Capacity (TAC), Malondialdehyde (MDA) and serum 8-Hydroxy-2-deoxiguanosine (8-OHdG) were measured in 297 patients with type 2 diabetes and 188 healthy individuals. Selection of cases and healthy individuals was done using random sampling technique. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 18.0 and a p-value

BACKGROUND Advances in technology have made available different types of glucose meters for use at the patient’s bed side with significant variation in accuracy among these glucose meters. OBJECTIVES We evaluated the accuracy of three commonly used glucose meters in a children emergency room using laboratory method as reference. SUBJECTS Subjects were 206 children seen in emergency room over a period of 3 months. METHODS Capillary blood glucose was determined at the bed side using three glucose meters: Accu - Chek” Active, On Call” Plus and One Touch” Ultra Mini. Peripheral venous blood was simultaneously collected for comparative plasma glucose analysis at the laboratory. The mean absolute relative deviations (MARDs) were determined. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS The MARD for Accu - Chek” Active, On Call” Plus and One Touch” Ultra Mini were 11.58%, 27.00%, and 13.91% respectively. In the diagnosis of hyperglycaemia, the sensitivity and specificity for Accu - Chek” Active, On Call” Plus, One Touch” Ultra Mini were 83.3% and 96.3%, 94.4% and 79.3%, 94.4 and 94.7% respectively. The PPV and NPV for Accu - Chek” Active, On Call” Plus, One Touch” Ultra Mini were 68.1% and 98.4%, 30.4% and 99.3%, 62.9% and 99.4% respectively. Four cases of hypoglycaemia were detected by the laboratory method and the 3 glucose meters detected 3 out of the 4 correctly. CONCLUSION These three glucose meters varied in accuracy but the glucose values by the Accu - Chek” Active had the least variation from the laboratory results.

The study aimed to describe 1) students’ algebraic thinking ability of elementary school grade V, 2) students’ algebraic thinking ability of junior high school grade VII, and 3) the development of students’ algebraic thinking ability from elementary school kelas V to junior high school grade VII. This study was a cross-sectional design with quantitive descriptive approach. The subjects of this study were 77 students of elementary school grade V and 95 students of junior high school grade VII. The sampling technique method used was stratified purposive sampling techniques and of analysis techniques with a descriptive analysis. The instrument used were algebraic thinking problems that consist of 3 components, namely, generational, transformational, and global meta-level activity. The results showed that 1) the students’ algebraic thinking ability of elementary school grade V was in the medium criteria; 2) the students’ algebraic thinking ability of junior high school grade VII was in medium criteria; 3) the average of gain score of students in junior high school grade VII was higher than students in elementary school grade V and students in elementary school grade V because lementary school students grade V until junior high school grade VII undergo a transition of thinking processes from arithmetic thinking to algebra thinking gradually, from simple cases to more complex cases. Generally, students of grade V and VII have moderate algebraic thinking skills. However, the ability of students of grade VII is higher than students of grade V because they have formally obtained algebra material. AbstrakPenelitian ini bertujuan untuk mendeskripsikan 1) kemampuan berpikir aljabar siswa Sekolah Dasar kelas V, 2) kemampuan berpikir aljabar siswa Sekolah Menengah Pertama kelas VII, dan 3) perkembangan kemampuan berpikir aljabar siswa dari sekolah dasar hingga sekolah menengah. Penelitian ini merupakan penelitian cross-sectional dengan pendekatan deskriptif kuantitatif. Subjek penelitian ini 77 siswa SD kelas V dan 95 siswa SMP kelas VII. Penentuan subjek penelitian dilakukan dengan teknik stratified purposive sampling dengan teknik analisis deskriptif. Instrumen yang digunakan berupa tes kemampuan berpikir aljabar yang memuat 3 komponen kegiatan yaitu kegiatan generasional, transformasional, dan global meta-level. Hasil penelitian menunjukkan bahwa: 1) kemampuan berpikir aljabar siswa SD kelas V berada dalam kriteria sedang; 2) kemampuan berpikir aljabar siswa SMP kelas VII berada dalam kriteria sedang; 3) rata-rata kemampuan siswa SMP kelas VII lebih tinggi dibanding rata-rata siswa SD kelas V karena siswa SD kelas V sampai dengan SMP kelas VII mengalami suatu transisi proses berpikir dari berpikir aritmatika menuju berpikir aljabar secara bertahap, mulai dari kasus sederhana sampai dengan kasus yang lebih kompleks. Kesimpulan, siswa kelas V dan kelas VII rata-rata memiliki kemampuan berpikir aljabar sedang. Namun, kemampuan siswa kelas VII lebih tinggi daripada siswa kelas V karena siswa Kelas VII telah memperoleh materi aljabar secara formal.

This research aims to describe the use of information and communication technologies in the learning of Islamic Education. Information and communication technology is electronic equipment consisting of hardware and software as well as all activities related to the processing, manipulation, management, and transfer of information antarmedia. Information and communication technology serves to produce quality information and communicative communication. This technology includes communications systems such as computers, televisions, video, and internet. This technology serves as a medium, and learning resources. The use of this technology in the learning of Islamic education will be able to facilitate the achievement of learning objectives and provide the learning motivation to learners so that they will be used to learn independently in search of information about the learning materials through the medium of information and communication technology.

Tujuan penelitian ini adalah untuk mendeskripsikan pengaruh pendekatan open-ended, pengaruh sekolah dan interaksi antara pendekatan open-ended dengan kategori sekolah terhadap prestasi belajar matematika, kemampuan berpikir kritis dan kepercayaan diri siswa SMP. Penelitian ini menggunakan penelitian eksperimen semu yang populasinya mencakup seluruh siswa kelas VII SMPN di Kecamatan Kebumen yang dikelompokkaan menjadi sekolah standar nasional (SSN) dan sekolah potensial. Sampel terdiri dari empat kelas yang dipilih secara acak dari masing-masing kategori sekolah. Teknik pengumpulan data dalam penelitian ini adalah tes dan nontes, sedangkan instrumen yang digunakan untuk mengumpulkan data meliputi soal tes prestasi belajar matematika, soal tes kemampuan berpikir kritis, dan angket kepercayaan diri siswa. Data yang dianalisis menggunakan uji statistik Analisis Varians Multivariat Dua Jalur (Two Way MANOVA) adalah data gain (gain score). Hasil penelitian pada taraf signifikan 5% menunjukkan bahwa ada pengaruh pendekatan open-ended terhadap prestasi belajar matematika, kemampuan berpikir kritis, dan kepercayaan diri siswa SMPN di Kecamatan Kebumen, tidak terdapat pengaruh sekolah serta tidak terdapat interaksi antara pendekatan open-ended dan sekolah terhadap prestasi belajar matematika, kemampuan berpikir kritis, dan kepercayaan diri siswa SMP. Kata Kunci: open-ended, prestasi belajar, kemampuan berpikir kritis, kepercayaan diri The Effect of Open-Ended on the Achievement, Critical Thinking and Self-Confidence of Junior High School Students Abstract The purpose of this study was to describe the effect of the open-ended approach, the effect of school, interaction of open-ended approach and the school categories on mathematics achievement, critical thinking and self-confidence in mathematic of public junior high school students. This study used quasi-experimental research that includes the entire population of students of class VIIth graders in junior high schools in District of Kebumen, classified into a standard national school (SSN) and potential school. The sample consists of four classes chosen at random from each category of the school. Data collection techniques in this research was a test and non-test while the instruments used to collect data covering mathematics,achievement test, critical thinking test, and questionnaire of the confidence of students. The data of gain score were analyzed using Multivariate Statistical analysis of variance test of two lines (Two Way MANOVA). The results of the study, using significance level 5%, showed that there was an effect of open-ended approach on mathematics achievement, critical thinking, and self-confidence of the students of public junior school in Kebumen District, there is no effect of school and there is no interaction of open-ended approach and schools on mathematics achievement, critical thinking and self confidence of the students of public junior high school. Keywords: open-ended, achievement, critical thinking, self-confidence

Penelitian ini bertujuan untuk mengembangkan modul pembelajaran matematika yang layak untuk pembelajaran siswa SMP N 1 Pomalaa kelas VII Sulawesi Tenggara. Penelitian pengembangan ini menggunakan model Borg & Gall. Subjek coba penelitian ini adalah siswa SMP N 1 Pomalaa kelas VII sejumlah 31 siswa, yang terdiri dari 6 siswa untuk uji coba terbatas dan 25 siswa untuk uji lapangan. Hasil penelitian menunjukkan bahwa modul pembelajaran geometri pada aspek kelayakan isi berkategori baik, pada aspek kelayakan bahasa dan gambar berkategori sangat baik, pada aspek penyajian berkategori sangat baik, dan pada aspek kegrafisan berkategori baik serta pembelajaran matematika yang menggunakan modul lebih baik dibandingkan kelas yang tidak menggunakan modul. Kata kunci: pengembangan, modul pembelajaran, pemahaman konsep dan minat Developing a Module to Improve Concept Understanding and Interest of Students of SMP Abstract The study aimed to develop appropiate mathematics instructional module for mathematics instruction for seventh grade students of SMP N 1 Pomalaa South-East Sulawesi. This research and development study used Borg and Gall model. Subject of research were 31 students of SMPN 1 Pomalaa. Specifically, 6 students participated in the limited try-out and 25 students participated in the extended try-out. The result of study shows that the module of geometry learning for seventh grade students of SMP N 1 Pomalaa in terms of the aspect of content was categorized good, from the aspect of language and pictures was categorized very good, from the aspect of lay-out was categorized very good, and from the aspect of graphic design was categorized good, and also mathematics learning using learning module was better than without module. Keywords : development, learning module, concept undertanding, interest

The death disease consider as material act can be prove it by all evidences such medical reports which make by specialized physics , presumption and scientific calculations. Also we can prove acts of sick person in dead disease by all official office which organized these acts from the date of diagnosis of dead disease and date of acts issue. Generally , providence of all disease hold on creditor or legal successor, the providence of sick person intention will be by law provision because the proved of this intention are so difficult if not impossible. .

This research concluded to point out that benevolence is a creed, a faith, a sharia, a behavior, an act of worship, morals, a saying, a practice, spending, patience, fidelity, truthfulness and piety. It is an inclusive name of all the mentioned values which Allah loves. if it is generalized, means all divine imperatives that Allah likes, hence it is interpreted as: faith, god-fearing, and righteous deeds. The research confirmed that it is desirable in itself, as it embraces the upright servant, because it's multitude proceeds, attributes of good and constituents of religion in the present and the hereafter life. The study explains its conception, indications, relationship with piety, Allah's naming himself with it, scopes, traits, status and rewards of the righteous. The study ends with the impacts of benevolence in the temporal and the last life, and concludes with the main following results: 1- The idiom "benevolence" is mentioned in Quran 20 times; Allah coupled it with piety in seven places in Quran, and preceded it in six of them. 2- benevolence is a way that leads to paradise. 3- Long life can be realized by benevolence. 4- Felicity can be achivied by benevolence in the present and the last life, mainly: tranquility in the temporal world the and safeguarding against the hereafter torment. 5- It realizes Allah's love for his righteous servants, which leads them to a high rank in the hereafter.

The essence of primary health care is the provision of essential health services and commodities to individuals and communities using available, acceptable and sustainable resources. However, there has been a growing lack of confidence by the populace as evidenced by poor utilization of the services. This study sought to identify the predominant barriers affecting the utilization of primary health care services in Batsari Local Government in Katsina State, Nigeria. A cluster of 630 households was surveyed in the catchment of the 21 health primary health facilities. A catchment been defined as a household located within 5 km of a primary health center. Using a three digit randomly generated numbers a household was selected. Once selected the start house and twenty-nine contiguous houses were visited. a total of 630 households were surveyed. In all households, questions were asked on the predominant health problems, as well as the major determinants of access and utilization of primary health care services .The results were computed and analyzed using the Statistical Package for Social Sciences software SPSS. Version 17.0. The findings from all the respondents (n=630) showed that majority of the people preferred to seek care from the patent medicine stores (53.63%) as against only 7.6% who utilized the primary health care services. The commonest reasons why respondents do not utilize these services were lack of essential drugs, high cost of services as well as inadequate infrastructure in primary healthcare facilities. The study has highlighted some of the multiple factors affecting the utilization of primary healthcare services. It is expected that these findings will guide policy makers in improving healthcare delivery particularly where the need is greatest - at the grassroots - in line with the national health policy and national health strategic development plan.

Background: The safety and efficacy of antenatal glucocorticoids in women in low-resource countries who are at risk for preterm birth are uncertain., Methods: We conducted a multicountry, randomized trial involving pregnant women between 26 weeks 0 days and 33 weeks 6 days of gestation who were at risk for preterm birth. The participants were assigned to intramuscular dexamethasone or identical placebo. The primary outcomes were neonatal death alone, stillbirth or neonatal death, and possible maternal bacterial infection; neonatal death alone and stillbirth or neonatal death were evaluated with superiority analyses, and possible maternal bacterial infection was evaluated with a noninferiority analysis with the use of a prespecified margin of 1.25 on the relative scale., Results: A total of 2852 women (and their 3070 fetuses) from 29 secondary- and tertiary-level hospitals across Bangladesh, India, Kenya, Nigeria, and Pakistan underwent randomization. The trial was stopped for benefit at the second interim analysis. Neonatal death occurred in 278 of 1417 infants (19.6%) in the dexamethasone group and in 331 of 1406 infants (23.5%) in the placebo group (relative risk, 0.84; 95% confidence interval [CI], 0.72 to 0.97; P = 0.03). Stillbirth or neonatal death occurred in 393 of 1532 fetuses and infants (25.7%) and in 444 of 1519 fetuses and infants (29.2%), respectively (relative risk, 0.88; 95% CI, 0.78 to 0.99; P = 0.04); the incidence of possible maternal bacterial infection was 4.8% and 6.3%, respectively (relative risk, 0.76; 95% CI, 0.56 to 1.03). There was no significant between-group difference in the incidence of adverse events., Conclusions: Among women in low-resource countries who were at risk for early preterm birth, the use of dexamethasone resulted in significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of placebo, without an increase in the incidence of possible maternal bacterial infection. (Funded by the Bill and Melinda Gates Foundation and the World Health Organization; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000476336; Clinical Trials Registry-India number, CTRI/2017/04/008326.)., (Copyright © 2020 Massachusetts Medical Society.)

The main objective of this secondary analysis was to describe the nutritional status of the Better Outcomes in Labour Difficulty (BOLD) project study population and determine possible associations between maternal nutritional status (as reflected by maternal BMI at the time of birth) and severe neonatal outcomes (SNO). We also analysed previous and index maternal pathologies to determine associations with neonatal outcomes. We used the classification designed by Atalah for maternal BMI and compared with the Hyperglycaemia and Adverse Pregnancy Outcome study one. To describe the nutritional status of this population, figures of distribution and test of normality related to weight and BMI were presented for the women and their babies. To explore the association between maternal BMI data and SNO, the χ2 test was performed. To identify a maternal characteristic or a group of characteristics that could predict SNO, we used Fisher's exact test using previous maternal pathology collected in the BOLD project as well as that in the index pregnancy. In this study, BMI at the time of birth was not associated with neonatal near miss or death. We found that previous maternal obesity, diabetes and chronic hypertension were associated with SNO. Maternal pathology in the index pregnancy such as other obstetric haemorrhage, pre-eclampsia, anaemia and gestational diabetes was associated with SNO.

A cross-sectional study using Spiritual Coping Questionnaire (SCQ) to explore the spiritual stress coping among Muslim Emergency and Critical Care nurses. 113 Participants were recruited. SCQ demonstrated good validation estimates. Positive religious behavior was the main spiritual coping with job stress. Likewise, spiritual coping was highly perceived as religious. Critical care nurses reported significantly higher positive social coping. Nurses with longer work experiences were significantly better in positive spiritual coping. Spiritual coping practices are highly prevalent in healthcare settings despite still lacking integration of spiritual components in its physical infrastructure, health policy and management.

Objective: To determine physicians` attitudes and stated practice in the management of patients with spinal muscular atrophy (SMA). We also aimed to explore their knowledge about consensus statement for standard of care in SMA and the role of new treatment modalities in changing the method of practice in the management of these cases., Methods: This is a quantitative observational cross-sectional study, conducted from February to May 2017 among physicians who manage SMA patients in Kingdom of Saudi Arabia. The study cohort included pediatric neurologists, adult neurologists, and physicians of other sub-specialties who manage SMA patients. We used online and paper-based questionnaires., Results: Half of the 169 participants were aware of the consensus guidelines for the care of SMA patients. With regard to the newly released Nursinersen treatment protocol for SMA-diagnosed patients, half of the participants were uncertain, and the other half were hesitant about its outcomes. Junior physicians tended to be significantly more inclined to reverse the do-not-resuscitate (DNR) status of an SMA-diagnosed child than more senior physicians., Conclusion: Our results indicate the existence of wide differences in physician practice with children of SMA disease. Our data demonstrate a need for increased awareness of consensus guidelines and further awareness about the physician`s role in the variability of care for children with SMA.

Background: Escalation in the global rates of labour interventions, particularly cesarean section and oxytocin augmentation, has renewed interest in a better understanding of natural labour progression. Methodological advancements in statistical and computational techniques addressing the limitations of pioneer studies have led to novel findings and triggered a re-evaluation of current labour practices. As part of the World Health Organization's Better Outcomes in Labour Difficulty (BOLD) project, which aimed to develop a new labour monitoring-to-action tool, we examined the patterns of labour progression as depicted by cervical dilatation over time in a cohort of women in Nigeria and Uganda who gave birth vaginally following a spontaneous labour onset., Methods and Findings: This was a prospective, multicentre, cohort study of 5,606 women with singleton, vertex, term gestation who presented at ≤ 6 cm of cervical dilatation following a spontaneous labour onset that resulted in a vaginal birth with no adverse birth outcomes in 13 hospitals across Nigeria and Uganda. We independently applied survival analysis and multistate Markov models to estimate the duration of labour centimetre by centimetre until 10 cm and the cumulative duration of labour from the cervical dilatation at admission through 10 cm. Multistate Markov and nonlinear mixed models were separately used to construct average labour curves. All analyses were conducted according to three parity groups: parity = 0 (n = 2,166), parity = 1 (n = 1,488), and parity = 2+ (n = 1,952). We performed sensitivity analyses to assess the impact of oxytocin augmentation on labour progression by re-examining the progression patterns after excluding women with augmented labours. Labour was augmented with oxytocin in 40% of nulliparous and 28% of multiparous women. The median time to advance by 1 cm exceeded 1 hour until 5 cm was reached in both nulliparous and multiparous women. Based on a 95th percentile threshold, nulliparous women may take up to 7 hours to progress from 4 to 5 cm and over 3 hours to progress from 5 to 6 cm. Median cumulative duration of labour indicates that nulliparous women admitted at 4 cm, 5 cm, and 6 cm reached 10 cm within an expected time frame if the dilatation rate was ≥ 1 cm/hour, but their corresponding 95th percentiles show that labour could last up to 14, 11, and 9 hours, respectively. Substantial differences exist between actual plots of labour progression of individual women and the 'average labour curves' derived from study population-level data. Exclusion of women with augmented labours from the study population resulted in slightly faster labour progression patterns., Conclusions: Cervical dilatation during labour in the slowest-yet-normal women can progress more slowly than the widely accepted benchmark of 1 cm/hour, irrespective of parity. Interventions to expedite labour to conform to a cervical dilatation threshold of 1 cm/hour may be inappropriate, especially when applied before 5 cm in nulliparous and multiparous women. Averaged labour curves may not truly reflect the variability associated with labour progression, and their use for decision-making in labour management should be de-emphasized.

Objective: "Negotiated standards" describe a level of quality of care that is acceptable and achievable within a specific health system, based on consensus between key stakeholders. This paper presents the development of negotiated standards for effective labor and childbirth care in selected hospitals and communities in Nigeria and Uganda., Methods: A four-step development process involving different methodologies. The process included: (1) review and synthesis of internationally recognized intrapartum clinical principles and practices; (2) primary qualitative research to assess values and preferences of women and healthcare providers, and practices that align with these preferences; (3) draft contextualization of effective and ineffective behaviors to reflect values and preferences; and (4) WHO-mediated negotiations between relevant stakeholders, including community members, providers, and administrators., Results: The primary outcomes of this process were a comprehensive set of effective behaviors and clinical practices covering the main domains of quality of care, which are practical and easy to communicate, implement, and audit across all levels of healthcare delivery., Conclusion: The process demonstrates that health facilities and providers can be motivated to adopt standards of care that uphold the values and preferences of both service users and providers, while adhering to international best practices., (© 2017 International Federation of Gynecology and Obstetrics. The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.)

Background: Global efforts have increased facility-based childbirth, but substantial barriers remain in some settings. In Nigeria, women report that poor provider attitudes influence their use of maternal health services. Evidence also suggests that women in Nigeria may experience mistreatment during childbirth; however, there is limited understanding of how and why mistreatment this occurs. This study uses qualitative methods to explore women and providers' experiences and perceptions of mistreatment during childbirth in two health facilities and catchment areas in Abuja, Nigeria., Methods: In-depth interviews (IDIs) and focus group discussions (FGDs) were used with a purposive sample of women of reproductive age, midwives, doctors and facility administrators. Instruments were semi-structured discussion guides. Participants were asked about their experiences and perceptions of, and perceived factors influencing mistreatment during childbirth. Thematic analysis was used to synthesize findings into meaningful sub-themes, narrative text and illustrative quotations, which were interpreted within the context of this study and an existing typology of mistreatment during childbirth., Results: Women and providers reported experiencing or witnessing physical abuse including slapping, physical restraint to a delivery bed, and detainment in the hospital and verbal abuse, such as shouting and threatening women with physical abuse. Women sometimes overcame tremendous barriers to reach a hospital, only to give birth on the floor, unattended by a provider. Participants identified three main factors contributing to mistreatment: poor provider attitudes, women's behavior, and health systems constraints., Conclusions: Moving forward, findings from this study must be communicated to key stakeholders at the study facilities. Measurement tools to assess how often mistreatment occurs and in what manner must be developed for monitoring and evaluation. Any intervention to prevent mistreatment will need to be multifaceted, and implementers should consider lessons learned from related interventions, such as increasing audit and feedback including from women, promoting labor companionship and encouraging stress-coping training for providers.

Background: Many women experience mistreatment during childbirth in health facilities across the world. However, limited evidence exists on how social norms and attitudes of both women and providers influence mistreatment during childbirth. Contextually-specific evidence is needed to understand how normative factors affect how women are treated. This paper explores the acceptability of four scenarios of mistreatment during childbirth., Methods: Two facilities were identified in Abuja, Nigeria. Qualitative methods (in-depth interviews (IDIs) and focus group discussions (FGDs)) were used with a purposive sample of women, midwives, doctors and administrators. Participants were presented with four scenarios of mistreatment during childbirth: slapping, verbal abuse, refusing to help the woman and physical restraint. Thematic analysis was used to synthesize findings, which were interpreted within the study context and an existing typology of mistreatment during childbirth., Results: Eighty-four IDIs and 4 FGDs are included in this analysis. Participants reported witnessing and experiencing mistreatment during childbirth, including slapping, physical restraint to a delivery bed, shouting, intimidation, and threats of physical abuse or poor health outcomes. Some women and providers considered each of the four scenarios as mistreatment. Others viewed these scenarios as appropriate and acceptable measures to gain compliance from the woman and ensure a good outcome for the baby. Women and providers blamed a woman's "disobedience" and "uncooperativeness" during labor for her experience of mistreatment., Conclusions: Blaming women for mistreatment parallels the intimate partner violence literature, demonstrating how traditional practices and low status of women potentiate gender inequality. These findings can be used to facilitate dialogue in Nigeria by engaging stakeholders to discuss how to challenge these norms and hold providers accountable for their actions. Until women and their families are able to freely condemn poor quality care in facilities and providers are held accountable for their actions, there will be little incentive to foster change.