Delays in Infant Hearing Detection and Intervention During the COVID-19 Pandemic: Commentary

Early detection and intervention for congenital hearing loss are critical for speech and language development. Newborns should receive hearing screening, diagnosis, and intervention by 1, 3, and 6 months, respectively. The COVID-19 pandemic has caused delays in each step of this process. Increased out-of-hospital births and shortages of essential health care services likely reduced the proportion of newborns completing screening. Additional factors have contributed to delayed diagnosis. We estimate that up to 50% of infants born with hearing loss in Maryland in 2021 may be delayed in diagnosis. Hearing loss interventions have been affected due to delayed initiation, reduced availability, and lack of in-person services. Delayed diagnosis and treatment of congenital hearing loss are likely to have significant effects on individual patients and public health, the full magnitude of which will not be known for years. Opportunities exist for providers to mitigate the negative effects of COVID-19 on pediatric hearing health care.

It's a Long Walk: Lasting Effects of Maternity Ward Openings on Labour Market Performance

Being born in a hospital versus having a traditional birth attendant at home represents the most common early life policy change worldwide. By applying a difference-in-differences approach to register-based individual-level data on the total population, this paper explores the long-term economic effects of the opening of new maternity wards as an early life quasi-experiment. It first finds that the reform substantially increased the share of hospital births and reduced early neonatal mortality. It then shows sizable long-term effects on labour income, unemployment, health-related disability and schooling. Small-scale local maternity wards yield a larger social rate of return than large-scale hospitals.

The Impact of Altitude at Birth on Perinatal Respiratory Support for Neonates with Trisomy 21

Objective Both high altitude and trisomy 21 (T21) status can negatively impact respiratory outcomes. The objective of this study was to examine the association between altitude and perinatal respiratory support in neonates with T21 compared with those without T21. Study Design This retrospective cohort study used the United States all-county natality files that included live, singleton, in-hospital births from 2015 to 2019. Descriptive statistics for neonates with and without the primary outcome of sustained assisted ventilation (>6 hours) were compared using t-tests and Chi-squared analyses. Multivariable logistic regression was used to determine the association between respiratory support and the presence of T21, and included an interaction term to determine whether the association between respiratory support and the presence of T21 was modified by elevation at delivery. Results A total of 17,939,006 neonates, 4,059 (0.02%) with T21 and 17,934,947 (99.98%) without, were included in the study. The odds of requiring sustained respiratory support following delivery were 5.95 (95% confidence interval [CI]: 5.31, 6.66), 4.06 (95% CI: 2.39, 6.89), 2.36 (95% CI: 1.64, 3.40), and 5.04 (95% CI: 1.54, 16.54) times as high for neonates with T21 than without T21 when born at low, medium, high, and very high elevations, respectively. The odds of requiring immediate ventilation support following delivery were 5.01 (95% CI: 4.59, 5.46), 5.90 (95% CI: 4.16, 8.36), 2.86 (95% CI: 2.15, 3.80), and 12.08 (95% CI: 6.78, 21.51) times as high for neonates with T21 than without T21 when born at low, medium, high, and very high elevation, respectively. Conclusion Neonates with T21 have increased odds of requiring respiratory support following delivery when compared with neonates without T21 at all categories of altitude. However, the odds ratios did not increase monotonically with altitude which indicates additional research is critical in understanding the effects of altitude on neonates with T21. Key Points

322Incidence, and mortality associated with primary postpartum haemorrhage following hospital births in northwest Ethiopia

Background Primary postpartum haemorrhage remains the primary cause of maternal mortality, in low-resource countries such as Ethiopia. National datasets about the incidence of primary postpartum haemorrhage are often limited, incomplete or unavailable. This study was designed to determine the incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births. Methods This was a cross-sectional study design, an audit of 1060 maternity care logbooks of discharged women. The data were abstracted December to May 2018/2019 using systematic random sampling. The tool used was the Facility Based Maternal Death Abstraction Form. Data were entered, cleaned then analysed using SPSS version 25. Bivariate logistic regression was fitted. Adjusted odds ratio with 95% confidence interval was used to determine the statistical significance. Results The incidence of primary postpartum haemorrhage was nearly 9.0% (95% CI: 6.91, 10.73). Of these, there was 7% maternal mortality. Unique to women in Ethiopia health facility referrals of women in labour (AOR: 2.13; 95% CI: 1.19, 3.80), birth attended by final year medical students (AOR: 3.59; 95% CI: 1.89, 6.84), women who were discharged as early as six hours following birth (AOR: 3.50; 95% CI: 1.24, 9.91) were associated with primary postpartum haemorrhage (p < 0.05). Conclusions The reported incidence of primary postpartum haemorrhage was relatively low, however, the associated deaths of women found was comparatively high. Key messages The increased maternal mortality appears to be directly related to the three delays model.

325The incidence of primary postpartum haemorrhage following in-hospital birth: a systematic review and meta-analysis

Background Although primary postpartum haemorrhage is a leading cause of maternal mortality, in the wider literature, there is inconsistent results in studies about its incidence. This study was designed to determine the pooled incidence of primary postpartum haemorrhage among women following in-hospital births. Methods This review used a systematic review and meta-analysis approach. We systematically searched electronic databases of Ovid MEDLINE, Ovid Emcare, Embase, PsycINFO, and CINAHL. Studies reporting the incidence of primary postpartum haemorrhage following in-hospital births were included. The pooled incidence of primary postpartum haemorrhage with a 95% confidence interval was calculated using random-effects model. Heterogeneity test between studies, and publication bias were assessed with I-square statistics and Egger’s test respectively. Results Ten of the 1548 studies were found to be eligible and were included in this systematic review and meta-analysis. The pooled incidence of primary postpartum haemorrhage following in-hospital births was nearly 12% (95% CI: 7.74- 17.61), with no evidence of between studies heterogeneity. Conclusions The incidence of primary postpartum haemorrhage following in-hospital births was high, and suggest that preventive strategies implemented to reduce its occurrence needs further strengthening using training. Key messages The result of this review suggests that globally at least one in ten women experience a primary postpartum haemorrhage following in-hospital births. This is higher than anticipated. The application of the recommended strategies for the prevention of primary postpartum haemorrhage should be re-emphasized.

Three kinds of caesarean sections: the foetal/neonatal perspective

In the age of hospital births, it is commonplace to contrast the vaginal route and the abdominal route as the basic classification. From the “point of view” of the foetus/neonate, we provide reasons to contrast “birth without labour” (that is birth by pre-labour caesarean section) and all the other vaginal and abdominal modes of birth. From a great diversity of theoretical reasons, one can anticipate that babies born by pre-labour caesarean sections are different from the others. We also provide reasons to popularize the concepts of “in labour non-emergency caesarean sections” and “planned in-labour caesarean sections”.

A Qualitative Study to Explore the Barriers for Nonadherence to Referral to Hospital Births by Women with High-Risk Pregnancies in Nepal

Maternal and neonatal morbidity and mortality tend to decrease if referral advice during pregnancy is utilized appropriately. This study explores the reasons for nonadherence to referral advice among high-risk pregnant women. A qualitative study was conducted in Morang District, Nepal. A phenomenological inquiry was used. Fourteen participants were interviewed in-depth. High-risk women who did not comply with the referral to have a hospital birth were the study participants. Participants were chosen purposively until data saturation was achieved. The data were generated using thematic analysis. Preference of homebirth, women’s diminished autonomy and financial dependence, conditional factors, and sociocultural factors were the four major themes that hindered hospital births. Women used antenatal check-ups to reaffirm normalcy in their current pregnancies to practice homebirth. For newly-wed young women, information barriers such as not knowing where to seek healthcare existed. The poorest segments and marginalized women did not adhere to referral hospital birth advice even when present with high-risk factors in pregnancy. Multiple factors, including socioeconomic and sociocultural factors, affect women’s decision to give birth in the referral hospital. Targeted interventions for underprivileged communities and policies to increase facility-based birth rates are recommended.