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1.  BMC Pregnancy and Childbirth reviewer acknowledgement 2014 
Contributing reviewers
The editors of BMC Pregnancy and Childbirth would like to thank all our reviewers who have contributed to the journal in Volume 14 (2014).
doi:10.1186/s12884-015-0443-1
PMCID: PMC4331299
2.  Epigenetic regulation of lncRNA connects ubiquitin-proteasome system with infection-inflammation in preterm births and preterm premature rupture of membranes 
Background
Preterm premature rupture of membranes (PPROM) is responsible for one third of all preterm births (PTBs). We have recently demonstrated that long noncoding RNAs (lncRNAs) are differentially expressed in human placentas derived from PPROM, PTB, premature rupture of the membranes (PROM), and full-term birth (FTB), and determined the major biological pathways involved in PPROM.
Methods
Here, we further investigated the relationship of lncRNAs, which are differentially expressed in spontaneous PTB (sPTB) and PPROM placentas and are found to overlap a coding locus, with the differential expression of transcribed mRNAs at the same locus. Ten lncRNAs (five up-regulated and five down-regulated) and the lncRNA-associated 10 mRNAs (six up- and four down-regulated), which were identified by microarray in comparing PPROM vs. sPTB, were then validated by real-time quantitative PCR.
Results
A total of 62 (38 up- and 24 down-regulated) and 1,923 (790 up- and 1,133 down-regulated) lncRNAs were identified from placentas of premature labor (sPTB + PPROM), as compared to those from full-term labor (FTB + PROM) and from premature rupture of membranes (PPROM + PROM), as compared to those from non-rupture of membranes (sPTB + FTB), respectively. We found that a correlation existed between differentially expressed lncRNAs and their associated mRNAs, which could be grouped into four categories based on the gene strand (sense or antisense) of lncRNA and its paired transcript. These findings suggest that lncRNA regulates mRNA transcription through differential mechanisms. Differential expression of the transcripts PPP2R5C, STAM, TACC2, EML4, PAM, PDE4B, STAM, PPP2R5C, PDE4B, and EGFR indicated a co-expression among these mRNAs, which are involved in the ubiquitine-proteasome system (UPS), in addition to signaling transduction and beta adrenergic signaling, suggesting that imbalanced regulation of UPS may present an additional mechanism underlying the premature rupture of membrane in PPROM.
Conclusion
Differentially expressed lncRNAs that were identified from the human placentas of sPTB and PPROM may regulate their associated mRNAs through differential mechanisms and connect the ubiquitin-proteasome system with infection-inflammation pathways. Although the detailed mechanisms by which lncRNAs regulate their associated mRNAs in sPTB and PPROM are yet to be clarified, our findings open a new approach to explore the pathogenesis of sPTB and PPROM.
doi:10.1186/s12884-015-0460-0
PMCID: PMC4335366
Preterm birth (PTB); Preterm premature rupture of membrane (PPROM); Long non-coding RNA (lncRNA); mRNA; Pathogenic mechanism
3.  Uterine artery Doppler in the management of early pregnancy loss: a prospective, longitudinal study 
Background
The pharmacological management of early pregnancy loss reduced substantially the need for dilation and curettage. However, prognostic markers of successful outcome were not established. Thus the major purpose of this study was to determine the sensitivity and specificity of the uterine artery pulsatility (PI) and resistance (RI) indices to detect early pregnancy loss patients requiring dilation and curettage after unsuccessful management.
Methods
A cohort prospective observational study was undertaken to include women with early pregnancy loss, ≤ 12 weeks of gestation, managed with mifepristone (200 mg) and misoprostol (1600 μg) followed by PI and RI evaluation of both uterine arteries 2 weeks after. At this time, in 173/315 patients, incomplete miscarriage was diagnosed. Among them, 32 underwent uterine dilatation and curettage at 8 weeks of follow-up.
Results
The cut-off points for the uterine artery PI and RI, leading to the maximum values of sensitivity (69.5%, CI95%: 61.5%-76.5% and 75.0%, CI95%: 57.9%-86.8%, respectively) and specificity (75.0%, CI95%: 57.9%-86.8% and 65.6%, CI95%: 48.3%-79.6%, respectively), for the discrimination between the women who needed curettage from those who resolved spontaneously were 2.8 and 1, respectively.
Conclusions
The potential usefulness of uterine artery Doppler evaluation to predict the need for uterine curettage in patients submitted to medical treatment for early pregnancy loss was demonstrated.
doi:10.1186/s12884-015-0464-9
PMCID: PMC4332726
Early pregnancy loss; Incomplete miscarriage; Uterine artery Doppler
4.  Factors associated with childbirth self-efficacy in Australian childbearing women 
Background
Childbirth confidence is an important marker of women’s coping abilities during labour and birth. This study investigated socio-demographic, obstetric and psychological factors affecting self-efficacy in childbearing women.
Method
This paper presents a secondary analysis of data collected as part of the BELIEF study (Birth Emotions – Looking to Improve Expectant Fear). Women (n = 1410) were recruited during pregnancy (≤24 weeks gestation). The survey included socio-demographic details (such as age and partner support); obstetric details including parity, birth preference, and pain; and standardised psychological measures: CBSEI (Childbirth Self-efficacy Inventory), W-DEQ A (childbirth fear) and EPDS (depressive symptoms). Variables were tested against CBSEI first stage of labour sub-scales (outcome expectancy and self-efficacy expectancy) according to parity.
Results
CBSEI total mean score was 443 (SD = 112.2). CBSEI, W-DEQ, EPDS scores were highly correlated. Regardless of parity, women who reported low childbirth knowledge, who preferred a caesarean section, and had high W-DEQ and EPDS scores reported lower self-efficacy. There were no differences for nulliparous or multiparous women on outcome expectancy, but multiparous women had higher self-efficacy scores (p < .001). Multiparous women whose partner was unsupportive were more likely to report low self-efficacy expectancy (p < .05). Experiencing moderate pain in pregnancy was significantly associated with low self-efficacy expectancy in both parity groups, as well as low outcome expectancy in nulliparous women only. Fear correlated strongly with low childbirth self-efficacy.
Conclusion
Few studies have investigated childbirth self-efficacy according to parity. Although multiparous women reported higher birth confidence significant obstetric and psychological differences were found. Addressing women’s physical and emotional wellbeing and perceptions of the upcoming birth may highlight their level of self-efficacy for birth.
Trial registration
Australian New Zealand Controlled Trials Registry ACTRN12612000526875, 17th May 2012.
doi:10.1186/s12884-015-0465-8
PMCID: PMC4333169
Pregnancy; Childbirth self-efficacy; Parity; Caesarean section; Fear; Depression
5.  Urinary cortisol and depression in early pregnancy: role of adiposity and race 
Background
Depression before and during pregnancy is associated with adverse birth outcomes including low birth weight and preterm birth. Abnormal maternal cortisol has been hypothesized as one mediator between depression and adverse birth outcomes. The relationship between cortisol and depression in pregnancy is exhibited most strongly in the African American population, and most studies have focused either on circulating or placental levels of cortisol. The utility of urinary cortisol in early pregnancy related to depression and adiposity has not been investigated.
Methods
Twenty-five pregnant African American women identified by the Edinburgh Depression Scale as having depression were investigated and matched by body mass index (BMI), age, race, and infant birth weight centile to non-depressed subjects. Maternal urine and plasma cortisol in early pregnancy were quantified and investigated in relation to depression and adiposity.
Results
Morning urine cortisol levels tracked positively with plasma cortisol (r2 = 0.25, p < 0.001). However, no differences were observed in either urinary or plasma cortisol between depressed and non-depressed pregnant women. Plasma cortisol was significantly negatively associated with several measures of maternal adiposity including percent body fat (r2 = −0.10, p < 0.05), however this relationship was present only in the non-depressed women. In a post-hoc analysis, non-depressed non-obese women were found to have significantly higher cortisol levels compared to women with depression, obesity or both (p < 0.05).
Conclusions
Depressed pregnant women and non-depressed obese pregnant women evidence atypical cortisol levels compared to non-depressed non-obese pregnant women. Plasma cortisol in early pregnancy is negatively associated with measures of maternal adiposity. Atypical low circulating maternal cortisol among depressed (lean and obese) and non-depressed obese pregnant African American women may indicate hypothalamic-pituitary axis dysfunction in early pregnancy.
doi:10.1186/s12884-015-0466-7
PMCID: PMC4335360
Pregnancy; Depression; Obesity; Cortisol; Race
6.  Prior cesarean section is associated with increased preeclampsia risk in a subsequent pregnancy 
Background
To evaluate the impact of a prior cesarean section on preeclampsia risk in a subsequent pregnancy.
Methods
Study data were collected from the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service for 2006–2010. Patients who had their first delivery in 2006 and subsequent delivery between 2007 and 2010 in Korea were enrolled. The overall incidence of preeclampsia during the second pregnancy was estimated and to evaluate the risk of preeclampsia in the second pregnancy, a model of multivariate logistic regression analysis was performed with preeclampsia as the final outcome
Results
The risk of preeclampsia in any pregnancy was 2.17%; the risk in the first pregnancy was 2.76%, and that in the second pregnancy was 1.15%. During the second pregnancy, the risk of preeclampsia was 13.30% for women who had developed preeclampsia in their first pregnancy and 0.85% for those who had not. In the entire population, prior cesarean section was associated with preeclampsia risk in their subsequent pregnancy (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.13–1.41). Among women with and without preeclampsia in their first pregnancy, a prior cesarean section was associated with preeclampsia risk in their second pregnancy (OR, 1.35; 95% CI, 1.09–1.67; OR, 1.23; 95% CI, 1.08–1.40, respectively).
Conclusions
Our study showed that cesarean section in a first pregnancy was associated with increased preeclampsia risk in the second pregnancy. These results provide physicians with a preeclampsia risk evaluation method for a second pregnancy that they may aid counseling in patients.
doi:10.1186/s12884-015-0447-x
PMCID: PMC4335660
Cesarean section; Preeclampsia; Subsequent pregnancy
7.  Symphysis-fundus height measurement to predict small-for-gestational-age status at birth: a systematic review 
Background
Fetal growth restriction is among the most common and complex problems in modern obstetrics. Symphysis-fundus (SF) height measurement is a non-invasive test that may help determine which women are at risk. This study is a systematic review of the literature on the accuracy of SF height measurement for the prediction of small-for-gestational-age (SGA) status at birth in unselected and low-risk pregnancies.
Methods
The Medline, Embase, Cinahl, SweMed, and Cochrane Library databases were searched with no limitation on publication date (through September 2014), which returned 722 citations. Two reviewers then developed a short list of 51 publications of possible relevance and assessed them using the following inclusion criteria: cohort study of test accuracy performed in a routine prenatal care setting; SF height measurement for all participants; classification of SGA, defined as birth weight (BW) < 10th, 5th, or 3rd percentile or ≥ one or two standard deviations below the mean; study conducted in Northern, Western, or Central Europe; USA; Canada; Australia; or New Zealand; and sufficient data for 2 × 2 table construction. Quality of the included studies was assessed in duplicate using criteria suggested by the Cochrane Collaboration. Review Manager 5.3 software was used to analyze the data, including plotting of summary receiver operating curve spaces.
Results
Eight studies were included in the final dataset and seven were included in summary analyses. The sensitivity of SF height measurement for SGA (BW < 10th percentile) prediction ranged from 0.27 to 0.76 and specificity ranged from 0.79 to 0.92. Positive and negative likelihood ratios ranged from 1.91 to 9.09 and from 0.29 to 0.83, respectively.
Conclusions
SF height can serve as a clinical indicator along with other clinical findings, information about medical conditions, and previous obstetric history. However, SF height has high false-negative rates for SGA. Clinicians must understand the limitations of this test.
The protocol has been registered in the international prospective register of systematic reviews, PROSPERO (Registration No. CRD42014008928, http://www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42014008928).
Electronic supplementary material
The online version of this article (doi:10.1186/s12884-015-0461-z) contains supplementary material, which is available to authorized users.
doi:10.1186/s12884-015-0461-z
PMCID: PMC4328041
Small-for-gestational-age; Symphysis-fundus height; Pregnancy surveillance; Fetal growth; Fetal growth restriction
8.  Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review 
Background
The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC.
Methods
The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, ‘Effective Public Health Practice Project’. The primary outcome measure was VBAC rates.
Results
238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates.
Conclusions
This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only.
Electronic supplementary material
The online version of this article (doi:10.1186/s12884-015-0441-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12884-015-0441-3
PMCID: PMC4324420  PMID: 25652550
VBAC; Systematic review; Interventions; Clinicians
9.  Risk-adjusted operative delivery rates and maternal-neonatal outcomes as measures of quality assessment in obstetric care: a multicenter prospective study 
Background
Although the evaluation of caesarean delivery rates has been suggested as one of the most important indicators of quality in obstetrics, it has been criticized because of its controversial ability to capture maternal and neonatal outcomes. In an “ideal” process of labor and delivery auditing, both caesarean (CD) and assisted vaginal delivery (AVD) rates should be considered because both of them may be associated with an increased risk of complications.
The aim of our study was to evaluate maternal and neonatal outcomes according to the outlier status for case-mix adjusted CD and AVD rates in the same obstetric population.
Methods
Standardized data on 15,189 deliveries from 11 centers were prospectively collected. Multiple logistic regression was used to estimate the risk-adjusted probability of a woman in each center having an AVD or a CD. Centers were classified as “above”, “below”, or “within” the expected rates by considering the observed-to-expected rates and the 95% confidence interval around the ratio. Adjusted maternal and neonatal outcomes were compared among the three groupings.
Results
Centers classified as “above” or “below” the expected CD rates had, in both cases, higher adjusted incidence of composite maternal (2.97%, 4.69%, 3.90% for “within”, “above” and “below”, respectively; p = 0.000) and neonatal complications (3.85%, 9.66%, 6.29% for “within”, “above” and “below”, respectively; p = 0.000) than centers “within” CD expected rates. Centers with AVD rates above and below the expected showed poorer and better composite maternal (3.96%, 4.61%, 2.97% for “within”, “above” and “below”, respectively; p = 0.000) and neonatal (6.52%, 9.77%, 3.52% for “within”, “above” and “below”, respectively; p = 0.000) outcomes respectively than centers with “within” AVD rates.
Conclusions
Both risk-adjusted CD and AVD delivery rates should be considered to assess the level of obstetric care. In this context, both higher and lower-than-expected rates of CD and “above” AVD rates are significantly associated with increased risk of complications, whereas the “below” status for AVD showed a “protective” effect on maternal and neonatal outcomes.
doi:10.1186/s12884-015-0450-2
PMCID: PMC4324422
Operative delivery; Risk adjustment; Quality of care; Maternal outcome; Neonatal outcome
10.  Pregnant women’s preference and factors associated with institutional delivery service utilization in Debra Markos Town, North West Ethiopia: a community based follow up study 
Background
Majority of deaths from obstetric complications are preventable. But every pregnant woman face risks which may not always be detected through the risk assessment approach during antenatal care (ANC). Therefore, the presence of a skilled birth attendant in every delivery is the most critical intervention in reducing maternal mortality and morbidity. In Ethiopia the proportion of births attended by skilled personnel, is very low, even for women who have access to the services.
Methods
A community-based follow up study was conducted from January 17, 2012 to July 30, 2012, among 2nd and 3rd trimester’s pregnant women in Debre-Markos town, east Gojam Zone, Amhara Region, North West Ethiopia. Simple random sampling technique was used to get a total sample size of 422 participants.
Results
A total of 393 pregnant women were included in the study. The study revealed that 292(74.3%) of the pregnant women planned to deliver in a health institution. Of these 292 pregnant women 234 (80.14%) actually delivered in a health facility.
Age range from 15–19 year (AOR = 4.83, 95% CI = 1.562-12.641), college and above education of the pregnant women (AOR = 12.508, 95% CI = 1.082-14.557), ANC visit during the current pregnancy (AOR = 1.975, 95% CI = 1.021-3.392),perceived susceptibility and severity of pregnancy and delivery complication (AOR = 3.208, 95% CI = 1.262-8.155) and intention (preference) of pregnant women for place of delivery (AOR = 7.032, 95% CI = 3.045-10.234) are predictors of institutional delivery service utilization.
Conclusions
Preference for institutional delivery is low in the study area. Sociodemographic factors, perception about delivery complication, ANC follow up and their intentions for institutional delivery are among important predictors of institutional delivery.
doi:10.1186/s12884-015-0437-z
PMCID: PMC4324647  PMID: 25652361
11.  Determinants of delays in travelling to an emergency obstetric care facility in Herat, Afghanistan: an analysis of cross-sectional survey data and spatial modelling 
Background
Women’s delays in reaching emergency obstetric care (EmOC) facilities contribute to high maternal and perinatal mortality and morbidity in low-income countries, yet few studies have quantified travel times to EmOC and examined delays systematically. We defined a delay as the difference between a woman’s travel time to EmOC and the optimal travel time under the best case scenario. The objectives were to model travel times to EmOC and identify factors explaining delays. i.e., the difference between empirical and modelled travel times.
Methods
A cost-distance approach in a raster-based geographic information system (GIS) was used for modelling travel times. Empirical data were obtained during a cross-sectional survey among women admitted in a life-threatening condition to the maternity ward of Herat Regional Hospital in Afghanistan from 2007 to 2008. Multivariable linear regression was used to identify the determinants of the log of delay.
Results
Amongst 402 women, 82 (20%) had no delay. The median modelled travel time, reported travel time, and delay were 1.0 hour [Q1-Q3: 0.6, 2.2], 3.6 hours [Q1-Q3: 1.0, 12.0], and 2.0 hours [Q1-Q3: 0.1, 9.2], respectively. The adjusted ratio (AR) of a delay of the “one-referral” group to the “self-referral” group was 4.9 [95% confidence interval (CI): 3.8-6.3]. Difficulties obtaining transportation explained some delay [AR 2.1 compared to “no difficulty”; 95% CI: 1.5-3.1]. A husband’s very large social network (> = 5 people) doubled a delay [95% CI: 1.1-3.7] compared to a moderate (3-4 people) network. Women with severe infections had a delay 2.6 times longer than those with postpartum haemorrhage (PPH) [95% CI: 1.4-4.9].
Conclusions
Delays were mostly explained by the number of health facilities visited. A husband’s large social network contributed to a delay. A complication with dramatic symptoms (e.g. PPH) shortened a delay while complications with less-alarming symptoms (e.g. severe infection) prolonged it. In-depth investigations are needed to clarify whether time is spent appropriately at lower-level facilities. Community members need to be sensitised to the signs and symptoms of obstetric complications and the urgency associated with them. Health-enhancing behaviours such as birth plans should be promoted in communities.
doi:10.1186/s12884-015-0435-1
PMCID: PMC4326321  PMID: 25652262
Afghanistan; Delays; Emergency obstetric care; Referrals; Maternal health; Near-miss; Geographic information systems; Social network; Transportation
12.  Contribution of prepregnancy body mass index and gestational weight gain to adverse neonatal outcomes: population attributable fractions for Canada 
Background
Low or high prepregnancy body mass index (BMI) and inadequate or excess gestational weight gain (GWG) are associated with adverse neonatal outcomes. This study estimates the contribution of these risk factors to preterm births (PTBs), small-for-gestational age (SGA) and large-for-gestational age (LGA) births in Canada compared to the contribution of prenatal smoking, a recognized perinatal risk factor.
Methods
We analyzed data from the Canadian Maternity Experiences Survey. A sample of 5,930 women who had a singleton live birth in 2005-2006 was weighted to a nationally representative population of 71,200 women. From adjusted odds ratios, we calculated population attributable fractions to estimate the contribution of BMI, GWG and prenatal smoking to PTB, SGA and LGA infants overall and across four obstetric groups.
Results
Overall, 6% of women were underweight (<18.5 kg/m2) and 34.4% were overweight or obese (≥25.0 kg/m2). More than half (59.4%) gained above the recommended weight for their BMI, 18.6% gained less than the recommended weight and 10.4% smoked prenatally. Excess GWG contributed more to adverse outcomes than BMI, contributing to 18.2% of PTB and 15.9% of LGA. Although the distribution of BMI and GWG was similar across obstetric groups, their impact was greater among primigravid women and multigravid women without a previous PTB or pregnancy loss. The contributions of BMI and GWG to PTB and SGA exceeded that of prenatal smoking.
Conclusions
Maternal weight, and GWG in particular, contributes significantly to the occurrence of adverse neonatal outcomes in Canada. Indeed, this contribution exceeds that of prenatal smoking for PTB and SGA, highlighting its public health importance.
doi:10.1186/s12884-015-0452-0
PMCID: PMC4326407  PMID: 25652811
Population attributable fraction; Maternal weight; Preterm birth; Small-for-gestational age; Large-for-gestational age
13.  A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda 
Background
Armed conflict has been described as an important contributor to the social determinants of health and a driver of health inequity, including maternal health. These conflicts may severely reduce access to maternal health services and, as a consequence, lead to poor maternal health outcomes for a period extending beyond the conflict itself. As such, understanding how maternal health-seeking behaviour and utilisation of maternal health services can be improved in post-conflict societies is of crucial importance. This study aims to explore the determinants (barriers and facilitators) of women’s uptake of maternal, sexual and reproductive health services (MSRHS) in two post-conflict settings in sub-Saharan Africa; Burundi and Northern Uganda, and how uptake is affected by exposure to armed conflict.
Methods
This is a qualitative study that utilised in-depth interviews and focus group discussions (FGDs) for data collection. One hundred and fifteen participants took part in the interviews and FGDs across the two study settings. Participants were women of reproductive age, local health providers and staff of non-governmental organizations. Issues explored included the factors affecting women’s utilisation of a range of MSRHS vis-à-vis conflict exposure. The framework method, making use of both inductive and deductive approaches, was used for analyzing the data.
Results
A complex and inter-related set of factors affect women’s utilisation of MSRHS in post-conflict settings. Exposure to armed conflict affects women’s utilisation of these services mainly through impeding women’s health seeking behaviour and community perception of health services. The factors identified cut across the individual, socio-cultural, and political and health system spheres, and the main determinants include women’s fear of developing pregnancy-related complications, status of women empowerment and support at the household and community levels, removal of user-fees, proximity to the health facility, and attitude of health providers.
Conclusions
Improving women’s uptake of MSRHS in post-conflict settings requires health system strengthening initiatives that address the barriers across the individual, socio-cultural, and political and health system spheres. While addressing financial barriers to access is crucial, attention should be paid to non-financial barriers as well. The goal should be to develop an equitable and sustainable health system.
Electronic supplementary material
The online version of this article (doi:10.1186/s12884-015-0449-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12884-015-0449-8
PMCID: PMC4327793  PMID: 25652727
Maternal health; Determinants; Post-conflict; Service utilisation
14.  Supporting aboriginal knowledge and practice in health care: lessons from a qualitative evaluation of the strong women, strong babies, strong culture program 
Background
The Strong Women, Strong Babies, Strong Culture Program (the Program) evolved from a recognition of the value of Aboriginal knowledge and practice in promoting maternal and child health (MCH) in remote communities of the Northern Territory (NT) of Australia. Commencing in 1993 it continues to operate today. In 2008, the NT Department of Health commissioned an evaluation to identify enabling factors and barriers to successful implementation of the Program, and to identify potential pathways for future development. In this paper we focus on the evaluation findings related specifically to the role of Aborignal cultural knowledge and practice within the Program.
Methods
A qualitative evaluation utilised purposive sampling to maximise diversity in program history and Aboriginal culture. Semi-structured, in-depth interviews with 76 participants were recorded in their preferred language with a registered Interpreter when required. Thematic analysis of data was verified or modified through further discussions with participants and members of the evaluation team.
Results
Although the importance of Aboriginal knowledge and practice as a fundamental component of the Program is widely acknowledged, there has been considerable variation across time and location in the extent to which these cultural dimensions have been included in practice. Factors contributing to this variation are complex and relate to a number of broad themes including: location of control over Program activities; recognition and respect for Aboriginal knowledge and practice as a legitimate component of health care; working in partnership; communication within and beyond the Program; access to transport and working space; and governance and organisational support.
Conclusions
We suggest that inclusion of Aboriginal knowledge and practice as a fundamental component of the Program is key to its survival over more than twenty years despite serious challenges. Respect for the legitimacy of Aboriginal knowledge and practice within health care, a high level of community participation and control supported through effective governance and sufficient organisational commitment as well as competence in intercultural collaborative practice of health staff are critical requirements for realising the potential for cultural knowledge and practice to improve Aboriginal health outcomes.
doi:10.1186/s12884-015-0433-3
PMCID: PMC4328040  PMID: 25652186
Maternal and child health; Indigenous health; Aboriginal culture; Intercultural health care
15.  Victorian paramedics’ encounters and management of women in labour: an epidemiological study 
Background
Although it is generally accepted that paramedics attend unexpected births, there is a paucity of literature about their management of women in labour. This study aimed to investigate the caseload of women in labour attended by a statewide ambulance service in Australia during one year and the management provided by paramedics.
Methods
Retrospective clinical data collected on-scene by paramedics via in-field electronic patient care records were provided by Ambulance Victoria. Patient case reports were electronically extracted from the Ambulance Victoria’s Clinical Data Warehouse via comprehensive filtering followed by manual sorting. Descriptive statistics were analysed using Statistical Package for Social Sciences (SPSS v.19).
Results
Over a 12-month period, paramedics were called to 1517 labouring women. Two thirds of women were at full-term gestation, and 40% of pre-term pregnancies were less than 32 weeks gestation. Paramedics documented 630 case reports of women in early labour and a further 767 in established labour. There were 204 women thought to be second stage labour, including 134 who progressed to childbirth under paramedic care. When paramedics assisted with births, the on-scene time was significantly greater than those patients transported in labour. Pain relief was provided significantly more often to women in established labour than in early labour. Oxygen was given to significantly more women in preterm labour. While paramedics performed a range of procedures including intravenous cannulation, administration of analgesia and oxygen, most women required minimal intervention. Paramedics needed to manage numerous obstetric and medical complications during their management.
Conclusions
Paramedics provide emergency care and transportation for women in labour. Most of the women were documented to be at term gestation with minimal complications. To enable appropriate decision making about management and transportation, paramedics require a range of clinical assessment skills comprising essential knowledge about antenatal and intrapartum care.
doi:10.1186/s12884-015-0430-6
PMCID: PMC4332426  PMID: 25652103
Labour; Birth; Childbirth; Paramedics; Ambulance
16.  Quality of intrapartum care by skilled birth attendants in a refugee clinic on the Thai-Myanmar border: a survey using WHO Safe Motherhood Needs Assessment 
Background
Increasing the number of women birthing with skilled birth attendants (SBAs) as one of the strategies to reduce maternal mortality and morbidity must be partnered with a minimum standard of care. This manuscript describes the quality of intrapartum care provided by SBAs in Mae La camp, a low resource, protracted refugee context on the Thai-Myanmar border.
Methods
In the obstetric department of Shoklo Malaria Research Unit (SMRU) the standardized WHO Safe Motherhood Needs Assessment tool was adapted to the setting and used: to assess the facility; interview SBAs; collect data from maternal records during a one year period (August 2007 – 2008); and observe practice during labour and childbirth.
Results
The facility assessment recorded no ‘out of stock’ or ‘out of date’ drugs and supplies, equipment was in operating order and necessary infrastructure e.g. a stand-by emergency car, was present. Syphilis testing was not available. SBA interviews established that danger signs and symptoms were recognized except for sepsis and endometritis. All SBAs acknowledged receiving theoretical and ‘hands-on’ training and regularly attended deliveries. Scores for the essential elements of antenatal care from maternal records were high (>90%) e.g. providing supplements, recording risk factors as well as regular and correct partogram use. Observed good clinical practice included: presence of a support person; active management of third stage; post-partum monitoring; and immediate and correct neonatal care. Observed incorrect practice included: improper controlled cord traction; inadequate hand washing; an episiotomy rate in nulliparous women 49% (34/70) and low rates 30% (6/20) of newborn monitoring in the first hours following birth. Overall observed complications during labour and birth were low with post-partum haemorrhage being the most common in which case the SBAs followed the protocol but were slow to recognize severity and take action.
Conclusions
In the clinic of SMRU in Mae La refugee camp, SBAs were able to comply with evidence-based guidelines but support to improve quality of care in specific areas is required. The structure of the WHO Safe Motherhood Needs Assessment allowed significant insights into the quality of intrapartum care particularly through direct observation, identifying a clear pathway for quality improvement.
Electronic supplementary material
The online version of this article (doi:10.1186/s12884-015-0444-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12884-015-0444-0
PMCID: PMC4332741  PMID: 25652646
Skilled birth attendant; Health care quality assessment; Pregnancy and childbirth care; Safe motherhood; Refugee setting
17.  Implementation of the WHO safe childbirth checklist program at a tertiary care setting in Sri Lanka: a developing country experience 
Background
To study institutionalization of the World Health Organization’s Safe Childbirth Checklist (SCC) in a tertiary care center in Sri Lanka.
Method
A hospital-based, prospective observational study was conducted in the De Soysa Hospital for Women, Colombo, Sri Lanka. Healthcare workers were educated regarding the SCC, which was to be used for each woman admitted to the labor room during the study period. A qualitatively pretested, self-administered questionnaire was given to all nursing and midwifery staff to assess knowledge and attitudes towards the checklist. Each item of the SCC was reviewed for adherence.
Results
A total of 824 births in which the checklist used were studied. There were a total of births 1800 during the period, giving an adoption rate of 45.8%. Out of the 170 health workers in the hospital (nurses, midwives and nurse midwives) 98 answered the questionnaire (response rate = 57.6%). The average number of childbirth practices checked in the checklist was 21 out of 29 (95% CI 20.2, 21.3). Educating the mother to seek help during labor, after delivery and after discharge from hospital, seeking an assistant during labor, early breast-feeding, maternal HIV infection and discussing contraceptive options were checked least often. The mean level of knowledge on the checklist among health workers was 60.1% (95% CI 57.2, 63.1). Attitudes for acceptance of using the checklist were satisfactory. Average adherence to checklist practices was 71.3%. Sixty eight (69.4%) agreed that the Checklist stimulates inter-personal communication and teamwork. Increased workload, poor enthusiasm of health workers towards new additions to their routine schedule and level of user-friendliness of Checklist were limitations to its greater use.
Conclusions
Amongst users, the attitude towards the checklist was satisfactory. Adoption rate amongst all workers was 45.8% and knowledge regarding the checklist was 60.1%. These two factors are probably linked. Therefore prior to introducing it to a facility awareness about the value and correct use of the SCC needs to be increased, while giving attention to satisfactory staffing levels.
doi:10.1186/s12884-015-0436-0
PMCID: PMC4324022  PMID: 25648543
Safe childbirth; Checklist; World health organization; Sri Lanka
18.  Assessing post-abortion care in health facilities in Afghanistan: a cross-sectional study 
Background
Complications of abortion are one of the leading causes of maternal mortality worldwide, along with hemorrhage, sepsis, and hypertensive diseases of pregnancy. In Afghanistan little data exist on the capacity of the health system to provide post-abortion care (PAC). This paper presents findings from a national emergency obstetric and neonatal care needs assessment related to PAC, with the aim of providing insight into the current situation and recommendations for improvement of PAC services.
Methods
A national Emergency Obstetric and Neonatal Care Needs Assessment was conducted from December 2009 through February 2010 at 78 of the 127 facilities designated to provide emergency obstetric and neonatal care services in Afghanistan. Research tools were adapted from the Averting Maternal Death and Disability Program Needs Assessment Toolkit and national midwifery education assessment tools. Descriptive statistics were used to summarize facility characteristics, and linear regression models were used to assess the factors associated with providers’ PAC knowledge and skills.
Results
The average number of women receiving PAC in the past year in each facility was 244, with no significant difference across facility types. All facilities had at least one staff member who provided PAC services. Overall, 70% of providers reported having been trained in PAC and 68% felt confident in their ability to perform these services. On average, providers were able to identify 66% of the most common complications of unsafe or incomplete abortion and 57% of the steps to take in examining and managing women with these complications. Providers correctly demonstrated an average of 31% of the tasks required for PAC during a simulated procedure. Training was significantly associated with PAC knowledge and skills in multivariate regression models, but other provider and facility characteristics were not.
Conclusions
While designated emergency obstetric facilities in Afghanistan generally have most supplies and equipment for PAC, the capacity of healthcare providers to deliver PAC is limited. Therefore, we strongly recommend training all skilled birth attendants in PAC services. In addition, a PAC training package should be integrated into pre-service medical education.
Electronic supplementary material
The online version of this article (doi:10.1186/s12884-015-0439-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12884-015-0439-x
PMCID: PMC4320442  PMID: 25645657
Post-abortion care; Emergency obstetric and neonatal care; Afghanistan
19.  Progression from gestational diabetes to type 2 diabetes in one region of Scotland: an observational follow-up study 
Background
The aim of this study was to investigate long-term risk of type 2 diabetes (T2D) following a diagnosis of gestational diabetes and to identify factors that were associated with increased risk of T2D.
Methods
An observational cohort design was used, following up all women diagnosed with gestational diabetes mellitus (GDM) attending a Diabetes Antenatal Clinic in the Dundee and Angus region of Scotland between 1994 and 2004 for a subsequent diagnosis of T2D, as recorded on SCI-DC (a comprehensive diabetes clinical information system).
Results
There were 164 women in the study who were followed up until 2012. One quarter developed T2D after a pregnancy with GDM in a mean time period of around eight years. Factors associated with a higher risk of developing T2D after GDM were increased weight during pregnancy, use of insulin during pregnancy, higher glycated haemoglobin (HbA1c) levels at diagnosis of GDM, and fasting blood glucose.
Conclusions
These findings suggest there is a viable time window to prevent progression from GDM to T2D and highlights those women who are at the greatest risk and should therefore be prioritised for preventative intervention.
doi:10.1186/s12884-015-0457-8
PMCID: PMC4320450  PMID: 25643857
Gestational diabetes; Type 2 diabetes; Follow-up; United Kingdom
20.  Determinants of use of skilled birth attendant at delivery in Makueni, Kenya: a cross sectional study 
Background
Kenya has a maternal mortality ratio of 488 per 100,000 live births. Preventing maternal deaths depends significantly on the presence of a skilled birth attendant at delivery. Kenyan national statistics estimate that the proportion of births attended by a skilled health professional have remained below 50% for over a decade; currently at 44%, according to Kenya’s demographic health survey 2008/09 against the national target of 65%. This study examines the association of mother’s characteristics, access to reproductive health services, and the use of skilled birth attendants in Makueni County, Kenya.
Methods
We carried out secondary data analysis of a cross sectional cluster survey that was conducted in August 2012. Interviews were conducted with 1,205 eligible female respondents (15-49 years), who had children less than five years (0-59 months) at the time of the study. Data was analysed using SPSS version 17. Multicollinearity of the independent variables was assessed. Chi-square tests were used and results that were statistically significant with p-values, p < 0.25 were further included into the multivariable logistic regression model. Adjusted odds ratio (AOR) and their 95% confidence intervals were (95%) calculated. P value less than 0.05 were considered significant.
Results
Among the mothers who were interviewed, 40.3% (489) were delivered by a skilled birth attendant while 59.7% (723) were delivered by unskilled birth attendants. Mothers with tertiary/university education were more likely to use a skilled birth attendant during delivery, adjusted OR 8.657, 95% CI, (1.445- 51.853) compared to those with no education. A woman whose partner had secondary education was 2.9 times more likely to seek skilled delivery, adjusted odds ratio 2.913, 95% CI, (1.337- 6.348). Attending ANC was equally significant, adjusted OR 11.938, 95% CI, (4.086- 34.88). Living within a distance of 1- 5 kilometers from a facility increased the likelihood of skilled birth attendance, adjusted OR 95% CI, 1.594 (1.071- 2.371).
Conclusions
The woman’s level of education, her partner’s level of education, attending ANC and living within 5kms from a health facility are associated with being assisted by skilled birth attendants. Health education and behaviour change communication strategies can be enhanced to increase demand for skilled delivery.
doi:10.1186/s12884-015-0442-2
PMCID: PMC4324035  PMID: 25645900
Maternal Health; Skilled attendant; Delivery; Birth; Obstetric care; Kenya
21.  “We have been working overnight without sleeping”: traditional birth attendants’ practices and perceptions of post-partum care services in rural Tanzania 
Background
In many low-income countries, formal post-partum care utilization is much lower than that of skilled delivery and antenatal care. While Traditional Birth Attendants (TBAs) might play a role in post-partum care, research exploring their attitudes and practices during this period is scarce. Therefore, the aim of this study was to explore TBAs’ practices and perceptions in post-partum care in rural Tanzania.
Methods
Qualitative in-depth interview data were collected from eight untrained and three trained TBAs. Additionally, five multiparous women who were clients of untrained TBAs were also interviewed. Interviews were conducted in February 2013. Data were digitally recorded and transcribed verbatim. Qualitative content analysis was used to analyze data.
Results
Our study found that TBAs take care of women during post-partum with rituals appreciated by women. They report lacking formal post-partum care training, which makes them ill-equipped to detect and handle post-partum complications. Despite their lack of preparation, they try to provide care for some post-partum complications which could put the health of the woman at risk. TBAs perceive that utilization of hospital-based post-partum services among women was only important for the baby and for managing complications which they cannot handle. They are poorly linked with the health system.
Conclusions
This study found that the TBAs conducted close follow-ups and some of their practices were appreciated by women. However, the fact that they were trying to manage certain post-partum complications can put women at risk. These findings point out the need to enhance the communication between TBAs and the formal health system and to increase the quality of the TBA services, especially in terms of prompt referral, through provision of training, mentoring, monitoring and supervision of the TBA services.
doi:10.1186/s12884-015-0445-z
PMCID: PMC4324777  PMID: 25643622
Perceptions; Post-partum care services; Practices; Tanzania; Traditional birth attendants
22.  Gestational weight gain among American Samoan women and its impact on delivery and infant outcomes 
Background
As obesity has increased worldwide, so have levels of obesity during pregnancy and excess gestational weight gain (GWG). The aim of this paper was to describe GWG among American Samoan women and examine the association between GWG and four adverse pregnancy and infant outcomes: cesarean delivery, small- and large-for-gestational age (SGA/LGA), and infant overweight/obesity.
Methods
Data were extracted from prenatal care records of 632 Samoan women. Mixed-effects growth models were used to produce individual weight-for-gestational week curves from which second and third trimester weight gain was estimated. Binary logistic regression was used to examine associations between GWG and the outcomes of interest.
Results
Most women were overweight/obese in early pregnancy (86%) and 78% exceeded the Institute of Medicine GWG guidelines. Greater GWG in the second trimester and early pregnancy weight were independently associated with increased odds of a c-section (OR 1.40 [95% CI: 1.08, 1.83]) and OR 1.51 [95% CI: 1.17, 1.95], respectively). Risk of delivering a LGA infant increased with greater third trimester weight gain and higher early pregnancy weight, while second trimester weight gain was negatively associated with SGA. Risk of infant overweight/obesity at 12 months increased with early pregnancy weight (OR: 1.23 [95% CI: 1.01, 1.51]) and infant birthweight.
Conclusions
The high levels of pregnancy obesity and excessive GWG in American Samoa suggest that it is important for physicians to encourage women into prenatal care early and begin education about appropriate GWG and the potential risks of excess weight gain for both the mother and baby.
doi:10.1186/s12884-015-0451-1
PMCID: PMC4324802  PMID: 25643752
American Samoa; Birth size; Cesarean delivery; Gestational weight gain; Obesity
23.  Small for gestational age births among South Indian women: temporal trend and risk factors from 1996 to 2010 
Background
The birth weight and gestational age at birth are two important variables that define neonatal morbidity and mortality. In developed countries, chronic maternal diseases like hypertension, diabetes mellitus, renal disease or collagen vascular disease is the most common cause of intrauterine growth restriction (IUGR). Maternal nutrition, pregnancy induced hypertension, chronic maternal infections, and other infections such as cytomegalovirus, parvovirus, rubella and malaria are the other causes of IUGR. The present study examines the secular trend of Small for Gestational Age (SGA) over 15 years and risk factors for SGA from a referral hospital in India.
Methods
Data from 1996 to 2010 was obtained from the labour room register. A rotational sampling scheme was used i.e. 12 months of the year were divided into 4 quarters. Taking into consideration all deliveries that met the inclusion criteria, babies whose birth weights were less than 10th percentile of the cut off values specific for gestational ages, were categorized as SGA. Only deliveries of live births that occurred between 22 and 42 weeks of pregnancy were considered in this study. Besides bivariate analyses, multivariable logistic regression analysis was done. Nagelkerke R2 statistics and Hosmer and Lemeshow chi-square statistics were used as goodness of fit statistics.
Results
Based on the data from 36,674 deliveries, the incidence of SGA was 11.4% in 1996 and 8.4% in 2010. Women who had multiple pregnancies had the higher odds of having SGA babies, 2.8 (2.3-3.3) times. The women with hypertensive disease had 1.8 (1.5-1.9) times higher odds of having SGA. Underweight women had 1.7 (1.3 - 2.1) times and anaemic mothers had 1.29 (1.01 - 1.6) times higher odds. The mothers who had cardiac disease were 1.4 (1.01 - 2.0) times at higher odds for SGA. In teenage pregnancies, the odds of SGA was 1.3 (1.1 - 1.5) times higher than mothers in the age group 20 to 35 years.
Conclusions
There is a significant reduction in the incidence of SGA by 26% over 15 years. The women with the above modifiable risk factors need to be identified early and provided with health education on optimal birth weight.
doi:10.1186/s12884-015-0440-4
PMCID: PMC4324804  PMID: 25645738
Small for Gestational Age; Birth weight; Risk factors; Incidence; Trend; Obstetric variables
24.  A prospective cohort study of depression in pregnancy, prevalence and risk factors in a multi-ethnic population 
Background
Depression in pregnancy increases the risk of complications for mother and child. Few studies are done in ethnic minorities. We wanted to identify the prevalence of depression in pregnancy and associations with ethnicity and other risk factors.
Method
Population-based, prospective cohort of 749 pregnant women (59% ethnic minorities) attending primary antenatal care during early pregnancy in Oslo between 2008 and 2010. Questionnaires covering demographics, health problems and psychosocial factors were collected through interviews. Depression in pregnancy was defined as a sum score ≥ 10 by the Edinburgh Postnatal Depression Scale (EPDS) at gestational week 28.
Results
The crude prevalence of depression was; Western Europeans: 8.6% (95% CI: 5.45-11.75), Middle Easterners: 19.5% (12.19-26.81), South Asians: 17.5% (12.08-22.92), and other groups: 11.3% (6.09-16.51). Median EPDS score was 6 in Middle Easterners and 3 in all other groups.
Middle Easterners (OR = 2.81; 95% CI (1.29-6.15)) and South Asians (2.72 (1.35-5.48)) had significantly higher risk for depression than other minorities and Western Europeans in logistic regression models. When adjusting for socioeconomic position and family structure, the ORs were reduced by 16-18% (OR = 2.44 (1.07-5.57) and 2.25 (1.07-4.72). Other significant risk factors were the number of recent adverse life events, self-reported history of depression and poor subjective health three months before conception.
Conclusion
The prevalence of depression in pregnancy was higher in ethnic minorities from the Middle East and South Asia. The increased risk persisted after adjustment for risk factors.
doi:10.1186/s12884-014-0420-0
PMCID: PMC4310137  PMID: 25616717
Depression; Mental health; Risk factors; EPDS; Pregnancy; Ethnic groups
25.  Sero-conversion rate of Syphilis and HIV among pregnant women attending antenatal clinic in Tanzania: a need for re-screening at delivery 
Background
Despite the available cost effective antenatal testing and treatment, syphilis and human immunodeficiency virus (HIV) are still among common infections affecting pregnant women especially in developing countries. In Tanzania, pregnant women are tested only once for syphilis and HIV during antenatal clinic (ANC) visits. Therefore, there are missed opportunities for syphilis and HIV screening among those who were not tested during ANC visits and those acquiring infections during the course of pregnancy. This study was designed to determine the syphilis and HIV seroprevalence at delivery and seroconversion rate among pregnant women delivering at Bugando Medical Centre (BMC).
Methods
A cross sectional, hospital-based study involving pregnant women attending Bugando Medical Centre (BMC) antenatal clinic was done from January to March 2012. Serum samples were collected and tested for HIV and syphilis using HIV and syphilis rapid tests. Demographic and clinical data were collected using a standardized data collection tool and analysed using STATA version 11.
Results
A total of 331 and 408 women were screened for syphilis and HIV during antenatal respectively. Of 331 women who screened negative for syphilis at ANC, nine (2.7%) were seropositive at delivery while of 391who tested negative for HIV during ANC eight (2%) were found to be positive at delivery. Six (1.8%) and 23 (9%) of women who did not screen for syphilis and HIV at ANC were seropositive for syphilis and HIV at delivery respectively. There was significant difference of seroprevalence for HIV, among women who tested negative at ANC and those who did not test at ANC (2% vs.9%, P,<0.001). The overall prevalence of syphilis and HIV at delivery was 15 (2.3%) and 48 (7.2%) respectively. Syphilis seropositivity at delivery was significantly associated with HIV co-infection (p < 0.001), male partner circumcision (p = 0.011) and alcohol use among women (p < 0.001).
Conclusions
The current protocol of screening for syphilis and HIV only once during pregnancy as practiced in Tanzania may miss women who get re-infected and seroconvert during pregnancy. Re-screening for syphilis and HIV during the course of pregnancy and at delivery is recommended in Tanzania as it can help to identify such women and institute appropriate treatment.
doi:10.1186/s12884-015-0434-2
PMCID: PMC4307991  PMID: 25613487
Syphilis; Treponema pallidum; Human immunodeficiency virus; Seroprevalence; Seroconversion; Sexually transmitted infection

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