Sarah Hansen

and 14 more

Objective: Assess to what extent caesarean section (CS) indications followed evidence-based, locally co-created guidelines and identify reasons contributing to non-medically indicated CSs. Design: Retrospective cross-sectional study. Setting: Five urban, high-volume maternity units in Dar es Salaam, Tanzania. Population: Women underwent CS during a three-month period at each maternity unit, between 1. October 2021 and 31. August 2022. Exclusion criteria: unavailable records or unknown indication. Methods: Case files of CS were audited against pre-defined, localised criteria. Main Outcome Measures: CS rate, indications and proportion of non-medically indicated CSs. Results: The CS rate was 31% (2949/9364); 2674/2949 (91%) CSs were included for analysis. Main indications were previous CS (1133/2674; 42%), prolonged labour (746/2674; 28%), and fetal distress (554/2674; 21%). Overall, 1061/2674 (40%) did not comply with audit criteria, main reasons being one previous CS with no trial of labour (526/1061; 50%); reported prolonged labour without actual slow labour progress (243/1061; 23%); and fetal distress with normal FHR (120-160 BPM) at time of decision (225/1061; 21%). Conclusion: Two in five CSs were categorised as non-medically indicated at time of decision. Particularly, fear of poor outcomes and delay in accessing emergency surgery may cause resource-consuming ‘defensive decision-making’ for CS. Investments in conducive urban maternity units are crucial to ensure safe vaginal births and to reach a population-based approach to ensure best possible timely care for all with the limited resources available. Funding: Danida Fellowship Centre, Denmark (18-08-KU), Aarhus University Research Foundation and Laerdal Global Health (2021-0095; 40662).
Objective: To estimate the proportion of caesarean sections (CS) not meeting audit criteria for prolonged labour. Design: Cross-sectional. Setting: Five urban maternity units in Dar es Salaam, Tanzania. Population: Women giving birth by CS with an indication of prolonged labour, from October 1 st, 2021 to August 31 st, 2022. Exclusion criteria: referral to the study sites because of prolonged labour or cervical dilatation >6 cm upon admission; non-cephalic presentation; multiple pregnancy; intrauterine fetal death; failed induction; previous CS; or other reasons for CS. Methods: Criterion-based audit of CS case files with an indication of prolonged labour. Main Outcome Measure : CSs in women with uncomplicated labour progress. Results: Overall CS rate was 32% (2949/9364) and 746/1517 (47.9%) of first-time CSs were performed because of prolonged labour. Out of these, 456 met inclusion criteria and 243/456 (53.3%) CSs were in uncomplicated labour: 1) women not being given a trial of labour (78/243, 32.1%); 2) women in first stage of active labour not crossing the partograph action line (145/243, 59.7%); and 3) women in second stage less than 1 hour (20/243 8.2%). Conclusion: Almost half of CS in the unscarred uterus were because of prolonged labour and many did not meet audit criteria for prolonged labour. Crowded hospitals and inadequate monitoring may have prompted defensive decision-making. Unconducive labour wards may, therefore, indirectly drive the CS epidemic while clinical guidelines for CS decision-making remain scarce.

Natasha Housseine

and 8 more

BJOG Commentary  Title: Fetal movement trials: where is the evidence in settings with high burden of stillbirths?Authors: Natasha Housseine1,2, [email protected], [email protected] Browne2, [email protected] Maaløe3 [email protected] Sequeira Dmello1,4 [email protected] Ali2,5, [email protected] Abeid1, [email protected] Meguid6, [email protected] J Rijken2,7,8, [email protected] Kidanto1, [email protected] Affiliations 1.      Aga Khan University, Medical College East Africa, Dar es Salaam campus2.      Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands3.      Global Health Section, Department of Public Health, University of Copenhagen, Denmark4.      Comprehensive Community Based Rehabilitation in Tanzania, Dar es salaam, Tanzania5.      Research Department, Ernest Cook Ultrasound Research and Education Institute (ECUREI), P.O. Box 7161, Kampala, Uganda6.      Child Health Unit, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa7.      Vrouw en Baby department, University Medical Centre Utrecht, Utrecht University, The Netherlands8.      Obstetric department, Amsterdam University Medical Center, Amsterdam, The Netherlands Corresponding author:Natasha HousseineThe Aga Khan University Medical CollegeUfukoni Road, P. O. Box 38129, Dar es salaam, Tanzania Telephone: +255 745 338 950  Fetal movement (FM) is a sign of fetal life and wellbeing that is felt by the pregnant woman, and reduced FM is known to precede stillbirths (1,2). Therefore, healthcare providers may advise women to monitor and report if their babies’ movements are fewer than usual. In high-income countries (HIC), there has been a renewed interest in FM with a recent wave of large-scale randomised controlled clinical trials investigating its potential to reduce stillbirths. The My Baby’s Movement trial in Australia/New Zealand, and the Mindfetalness trial in Sweden investigated the effects of intervention aimed at increasing women’s awareness of FM (3,4). The British AFFIRM trial investigated the effects of an FM awareness package coupled with a standardised management protocol (5). The ongoing CEPRA study in the Netherlands, UK and Australia and aims to evaluate Cerebro Placental Ratio as an indicator for delivery in women with reduced FM (6). None of the completed trials, however, found significant reductions in stillbirths. Moreover, they showed conflicting results on some potential harmful consequences, such as increased rates of obstetric interventions. In this commentary, we reflect on these trials through a global lens, and we urgently call for more trials – but this time in settings suffering the majority (98%) of the world’s two million annual stillbirths. Importantly, the global applicability of these HIC trials is questionable. They were conducted in settings where women are aware of the importance of reduced FM and are empowered to access highest standards of care. The contextual realities of pregnancy care are vastly different in low- and middle-income countries (LMICs) where antenatal care and health education are substandard. Women lack health information to self-monitor and report reduced FM. Furthermore, antenatal clinics are often overcrowded and understaffed, with lack of supplies, clinical guidelines, and adequate training of health workers. Recent estimates show stillbirth rates as high as 22 per 1000 per total births in Sub-Saharan Africa, compared to less than 3 per 1000 in HICs (7). Given the downward trend of stillbirths reported in all the HIC trials, it is possible that the completed trials may be demonstrating a lack of evidence rather than a lack of effectiveness. We hypothesise that involving women in their care, through training on how to monitor their baby’s movement and when and how to respond coupled with strengthening healthcare workers’ respect and response to women’s concerns on reduced FM, is a low-cost intervention with potential to significantly reduce stillbirths in high-burden LMICs. Surprisingly, high-quality studies from LMICs that have assessed the effect of FM interventions on perinatal deaths are lacking (2). Of note, the authors of the above-mentioned trials did not consider the well-known major differences in clinical context globally as a limitation while discussing the generalisability of their findings. In fact, the latest My Baby’s Movement trial was not even published open access, limiting access to less privileged clinicians, researchers and policymakers (4). This lack of a global perspective on the international health crisis of preventable stillbirths is an epistemic injustice and a missed opportunity (8). We are concerned that the results of the above trials could prematurely prompt policies discouraging the use of FM awareness among pregnant women (9). It is thus crucial that the lack of generic applicability of these trials’ findings are stressed, and that their high-resource contexts are considered when developing global clinical guidelines and future research priorities. Notably, it has been seen too often how the unbalanced evidence production from HICs has had unintended harmful influences on clinical practice in LMICs (10). For instance, it appears that the breech trials from HICs have led to policy change also in LMICs with increased use of caesarean section in case of breech presentation. However, the risk ratios of vaginal breech births versus caesarean sections differ dramatically between high-resource and low-resource settings with lower surgical safety in LMICs (11,12).The prevailing constraints in LMICs should stimulate innovation and creativity to design low-cost solutions that strengthen three areas 1) FM awareness and monitoring; 2) diagnosis to identify babies truly at risk, and 3) care provision protocols of pregnant women with reduced FM to improve perinatal outcomes. While such strategies or their evidence base are often lacking in LMICs, there is some evidence about possible low-cost diagnostic approaches to assess fetal risk following reduced FM: for example, measuring maternal blood pressure, fetal heart rate, and fundal height (13), or antenatal (hand-held) ultrasound to detect and monitor high-risk pregnancies. Measuring fetal blood flow in Doppler ultrasound studies has also been useful particularly in detecting growth restriction (6,14).  Involving women and health workers in studies will ensure consideration of health-system constraints and allow these to be embedded in the design, implementation, and evaluation of any new intervention. If proven effective, this will increase the chance of seamless integration of the intervention into existing care, positive perceptions by providers and pregnant women- and not increase the burden on already overwhelmed healthcare workers.  Unfortunately, maternal perception of FM is still too often the only signal of complications in the absence of regular high-quality antenatal checks (15)– and there are possibly many babies’ lives lost by ignoring this danger sign. Given the burden of need and the context-specific realities that determine interventions’ effectiveness, we hope these recent waves of FM trials will continue into LMICs to investigate if and how FM awareness coupled with context-tailored management protocol can reduce stillbirths.    Contribution to AuthorshipNH conceived and wrote the first draft. JB, NM, BSD and MJR contributed to subsequent drafting of the manuscript. All authors revised the commentary for important intellectual content and approved the final version to be published and agree to be accountable for all aspects of the work. Details of ethics approvalNo ethics approval applicable for this commentary FundingThere was no financial support for this commentary Disclosure of interests  Reference1.        Bekiou A, Gourounti K. Reduced Fetal Movements and Perinatal Mortality. Mater Sociomed. 2020;32(3). 2.        Hayes DJL, Smyth R, Heazell AEP. Investigating the significance and current state of knowledge and practice of absent or reduced fetal movements in low and lower middle-income countries : a scoping review. 2019;3:1–12. 3.        Akselsson A, Lindgren H, Georgsson S, Pettersson K, Steineck G, Skokic V, et al. Mindfetalness to increase women’s awareness of fetal movements and pregnancy outcomes: a cluster-randomised controlled trial including 39 865 women. BJOG An Int J Obstet Gynaecol. 2020 Jun 1;127(7):829–37. 4.        Flenady V, Gardener G, Ellwood D, Coory M, Weller M, Warrilow KA, et al. My Baby’s Movements: a stepped-wedge cluster-randomised controlled trial of a fetal movement awareness intervention to reduce stillbirths. BJOG An Int J Obstet Gynaecol. 2022 Jan 1;129(1):29–41. 5.        Norman JE, Heazell AEP, Rodriguez A, Weir CJ, Stock SJE, Calderwood CJ, et al. Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial. www.thelancet.com. 2018;392. 6.        Damhuis SE, Ganzevoort W, Duijnhoven RG, Groen H, Kumar S, Heazell AEP, et al. The CErebro Placental RAtio as indicator for delivery following perception of reduced fetal movements, protocol for an international cluster randomised clinical trial; the CEPRA study. BMC Pregnancy Childbirth. 2021 Dec 1;21(1). 7.        Hug L, You D, Blencowe H, Mishra A, Wang Z, Fix MJ, et al. Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. Lancet. 2021 Aug 28;398(10302):772–85. 8.        Bhakuni H, Abimbola S. Epistemic injustice in academic global health. Lancet Glob Heal. 2021;9:e1465–70. 9.        Walker KF, Thornton JG. Encouraging awareness of fetal movements is harmful. Lancet. 2018 Nov 3;392(10158):1601–2. 10.      Maaløe N, Ørtved AMR, Sørensen JB, Sequeira Dmello B, van den Akker T, Kujabi ML, et al. The injustice of unfit clinical practice guidelines in low-resource realities. Lancet Glob Heal. 2021;9(6):e875–9. 11.      van Roosmalen J, Meguid T. The dilemma of vaginal breech delivery worldwide. Lancet. 2014;338(9932): 12.      Sobhy S, Arroyo-Manzano D, Murugesu N, Karthikeyan G, Kumar V, Kaur I, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis. Lancet. 2019 May 11;393(10184):1973–82. 13.      Housseine N, Rijken MJ, Weller K, Nassor NH, Gbenga K, Dodd C, et al. Development of a clinical prediction model for perinatal deaths in low resource settings. eClinicalMedicine. 2022 Feb;44:101288. 14.      Ali S, Kawooya MG, Byamugisha J, Kakibogo IM, Biira EA, Kagimu AN, et al. Middle cerebral arterial flow redistribution is an indicator for intrauterine fetal compromise in late pregnancy in low-resource settings: a prospective cohort study. BJOG An Int J Obstet Gynaecol. 2022 Feb 4; 15.      World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. 2016 [cited 2020 Jul 30]. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/ ‘This article has a Video Abstract presented by Natasha Housseine.’