Sustainability of hospital-based midwife-led antenatal care consultation — a qualitative study

Background All evidence-based knowledge and improvement strategies for quality care must be implemented so patients can benefit from them. In Germany, national expert standards (NES) contribute to quality care in nursing and midwifery. The NES defines for several action levels a dedicated level of quality, which is operationalized by structure, process, and outcome (SPO) criteria. An NES to promote normal childbirth was developed and implemented in 2014. The first action level involves midwife-led antenatal consultation (ML-AC) being conducted in a structured way. Most implementation processes aim to accomplish sustainability, but implementation studies rarely use definitions or a theory of sustainability, even when assessing sustainability. This lack led to the assumption that intervention sustainability after implementation is still a largely unexplored domain. The aim of this study is to investigate the sustainability of midwife-led antenatal consultation (ML-AC) implemented at two hospitals, in Germany. Methods In a qualitative approach, 34 qualitative interviews were conducted (between March and October 2017) using semi-structured interview guides. All interviews were transcribed verbatim, anonymized and analyzed thematically using framework method. Four groups of stakeholders in two hospitals offering ML-AC were interviewed: managers (n = 8), midwives conducting ML-AC (n = 10), pregnant women who attended ML-AC (n = 8), and physicians working in obstetrics (n = 8) at the hospitals. Results The interviewees identified key benefits of ML-AC on a personal and unit level, e.g., reduced obstetric interventions, easier admission processes. Furthermore, the participants defined key requirements that are needed for routinized and institutionalized ML-AC, such as allocating working time for ML-AC, and structural organization of ML-AC. All study participants saw a need to establish secure long-term funding. Additionally, the interviewed staff members stated that ML-AC topics need evaluating and adapting in the future. Conclusions Implementing ML-AC in the hospital setting has led to manifold benefits. However, reimbursement through the health care system will be needed to sustain ML-AC. Hospitals implementing ML-AC will need to be aware that adaptations of the NES are necessary to accomplish routinization and institutionalization. After initial implementation, sustaining ML-AC will generally require on-going monitoring and evaluating of benefits, routinization/institutionalization and further development.

Bereaved Parents: Insights for the Antenatal Consultation

Objective The study aimed to explore experiences of extremely preterm infant loss in the delivery room and perspectives about antenatal consultation. Study Design Bereaved participants were interviewed, following a semi-structured protocol. Personal narratives were analyzed with a mixed-methods approach. Results In total, 13 participants, reflecting on 17 pregnancies, shared positive, healing and negative, harmful interactions with clinicians and institutions: feeling cared for or abandoned, doubted or believed, being treated rigidly or flexibly, and feeling that infant's life was valued or not. Participants stressed their need for personalized information, individualized approaches, and affective support. Their decision processes varied; some wanted different things for themselves than what they recommended for others. These interactions shaped their immediate experiences, long-term well-being, healing, and regrets. All had successful subsequent pregnancies; few returned to institutions where they felt poorly treated. Conclusion Antenatal consultations can be strengthened by personalizing them, within a strong caregiver relationship and supportive institutional practices. Key Points

What Information Do Clinicians Deem Important for Counseling Parents Facing Extremely Early Deliveries?: Results from an Online Survey

Objective The study aimed to better understand how neonatology and maternal fetal medicine (MFM) physicians convey information during antenatal counseling that requires facilitating shared decision-making with parents facing options of resuscitation versus comfort care after extremely early delivery Study Design Attending physicians at US centers with both Neo and MFM fellowships were invited to answer an original online survey about antenatal counseling for extremely early newborns. The survey assessed information conveyed, processes for facilitating shared decision-making (reported separately), and clinical experiences. Neonatology and MFM responses were compared. Multivariable logistic regression analyzed topics often and seldom discussed by specialty groups with respect to respondents' clinical experience and resuscitation option preferences at different gestational weeks. Results In total, 74 MFM and 167 neonatologists representing 94% of the 81 centers surveyed responded. Grouped by specialty, respondents were similar in counseling experience and distribution of allowing choices between resuscitation and no resuscitation for delivery at specific weeks of gestational ages. MFM versus neonatology reported similar rates of discussing long-term health and developmental concerns and differed in all other categories of topics. Neonatologists were less likely than MFM to discuss caregiver impacts (odds ratio [OR]: 0.14, 95% confidence interval [CI]: 0.11–0.18, p < 0.001) and comfort care details (OR: 0.19, 95% CI: 0.15–0.25, p < 0.001). Conversely, neonatology versus MFM respondents more frequently reported “usually” discussing topics pertaining to parenting in the NICU (OR: 1.5, 95% CI: 1.2–1.8, p < 0.001) and those regarding stabilizing interventions in the delivery room (OR: 1.8, 95% CI: 1.4–2.2, p < 0.001). Compared with less-experienced respondents, those with 17 years’ or more of clinical experience had greater likelihood in both specialties to say they “usually” discussed otherwise infrequently reported topics pertaining to caregiver impacts. Conclusion Parents require information to make difficult decisions for their extremely early newborns. Our findings endorse the value of co-consultation by MFM and neonatology clinicians and of trainee education on antenatal consultation education to support these families. Key Points

The Value of Magnesium Sulfate in the Pre-Hospital Phase of the Management of Eclampsia

Eclampsia is a very serious complication of pregnancy, its occurrence is responsible of maternal and fetal morbidity and mortality. The aim of this study is to clarify the value of Magnesium Sulfate in the prevention of convulsive state and in the choice of anesthetic technique for cesarean section during eclampsia. We realized a prospective descriptive, analytical and comparative study over a period of 5 months, concerning a series of 49 pregnant women admitted to the anesthesia-intensive care unit of the Souissi Maternity Hospital in Rabat, with eclampsia. The diagnosis of eclampsia was made due to the occurrence of convulsive seizure (s) linked to pregnancy-induced hypertension. It was found that eclampsia mainly affected young women (age less than or equal to 25 years) with a percentage of 57.3%. The majority of patients were first-time mothers (55.1%). This condition manifests itself most often in the last trimester of pregnancy (72.9%), especially in pre-partum. The majority of patients did not receive an antenatal consultation. The treatment of choice in our study was magnesium sulfate. So, 51% of patients had not received magnesium sulfate before their admission to our hospital and 56% of them had had more than one seizure. And the 49% of patients, on the other hand, had received magnesium sulfate and only 18% of them had had the seizure again. Our obstetric attitude was based on immediate delivery with a caesarean section. 34.5% cesarean sections were performed under general anesthesia, compared with 65.5% under spinal anesthesia. The fetus morbidity was mainly represented by prematurity (30.6%) and neonatal distress (28.5%). The prognosis of eclampsia remains bleak both for the mother with a maternal mortality rate of 4%, and for the fetus with a perinatal mortality rate of 16.3%.

Plasmodium falciparum Parasitaemia during Pregnancy and the Use of Malaria Prevention Methods by Women Attending Antenatal Consultation at the Regional Hospital Bamenda, Northwest Cameroon

Aims: The aims of this study were to determine the prevalence of Plasmodium falciparum parasitaemia in pregnant women and to identify the prevention methods used by pregnant women attending antenatal consultation (ANC) in the Regional Hospital Bamenda (RHB). Study Design: This was a hospital based cross sectional study. Place and Duration of Study: This study was carried out in the Regional Hospital Bamenda between April and May 2020. Methodology: A structured questionnaire was used to collect information on sociodemographic characteristics, history of pregnancy and the use of malaria prevention methods. Capillary blood was collected through finger prick and used to prepare thick and thin blood smears that were Giemsa-stained for the detection of malaria parasite by microscopy. Results: A total of 250 pregnant women took part in this study. The mean age ±SD was 27.71 ±5.47 years. The mean pregnancy age ±SD was 24.04 ±8.59 weeks. The prevalence of malaria parasitaemia was 18.0%. The most used malaria prevention method was LLINs (190/211, 91.0%). There was a statistically significant difference in MP prevalence between women who used IPTp (13.9%) and those who didn’t (26.5%) (χ2 =5.87, P= .02); between women who used bed nets and IPT (12.9%) in combination and those who didn’t (24.0%) (χ2 = 5.12, P= .03) as well as between participants who used at least one method (16.4%) and their counterparts who didn’t use any malaria prevention method (38.9%) (χ2=5.73, P=.01). Living in a house with plank or mud walls (13; 29.0%) was surprisingly more protective than living in a cement brick or mud brick house (30; 71.0%) (OR: 2.34; 95%CI: 1.10-4.97; P=.03). Conclusion: Malaria remains a health preoccupation among pregnant women attending ANC consultation in the RHB. Use of bed nets and IPTp as well as the use of at least one prevention method could be protective.

Partial molar pregnancy with live fetus in first trimester: what should we do next

The incidence of a normal live fetus with a partial mole is extremely rare, and it varies between 5 per 100000 and 1 per 10000 of the pregnancies. A partial molar pregnancy is a variation of a molar pregnancy in which an embryo either develops incompletely or with multiple structural anomalies.A 27-year-old Primigravide at 13 weeks of gestation got admitted with spotting per vaginam, excessive nausea and vomiting, and her ultrasound revealed a hydropic placenta with multiple cysts with a live fetus. Regarding these findings, the patient continued her pregnancy under close observation, and advanced sonographic evaluations were done to rule out other differentials. Ultrasonography found mosaicism in the partial mole (mostly diploid, a small part is triploid). In this condition, the prognosis condition for the fetus to be born safely is still probable. Ethics committee meetings are held with the consideration of the fetus's condition, whether monitoring is carried out regularly, and terminating the pregnancy in case of fetal emergency.The optimal management of hydatidiform mole with the coexistent live fetus is currently uncertain. Antenatal consultation should include a detailed discussion of maternal and fetal risks. It is also necessary to have close follow-up and evaluation of the patient's condition during the antenatal and postnatal period. Keywords: first trimester, live fetus , management, partial molar pregnancy

Determinants of Noncompletion of the Third Dose of Tetanus Toxoid Vaccine in Pregnant Women in Dschang Health District, Cameroon

Introduction. Tetanus vaccination plays an important role in the fight against neonatal mortality. Our study aimed to determine the noncompletion rate of the 3rd dose of tetanus toxoid vaccine (TTV) and to analyze the associated factors in pregnant women. Methods. This was a cross-sectional study conducted in 2 hospitals of Dschang Health District and targeting all women at least in their second gestation coming for antenatal consultation. Upon informed consent by the participant, a prepared questionnaire was administered. The collected data was analyzed using SPSS v22.0 with results presented in means and proportions. Logistic regression was used at two levels to identify independently associated factors for noncompletion of the third dose of TTV with a significance set at 5%. Results. A total of 380 pregnant women were recruited in this study of mean age 27 ± 5.2 yrs, 70% being married, more than 80% having at least secondary education, and 31.8% of them being students. It was noted that 172 (45.26%) of these women had not received the third dose of TTV. The analysis of the adjusted effects showed that not going to postnatal consultation (aOR = 6.75; 3.98–11.49, p<0.0001), not accompanying her baby to vaccination (aOR = 3.784; 1.803–7.942, p<0.0001), and being single (aOR = 1.87; 1.05–3.3, p=0.034) were independently associated with the above noncompletion rate. Conclusion. Tetanus vaccination coverage is not yet optimal in Dschang Health District and is associated with marital status as well as postgestational behavior of the mothers. There is thus the need to put in place strategies that will provide social support to single mothers as well as encourage women to attend postnatal consultation and to accompany their own children for vaccination. Furthermore, community-based vaccination could capture some of the lost women thus optimizing the overall vaccination coverage.

Schistosomiasis among pregnant women in Njombe-Penja health district, Cameroon

Introduction: Schistosomiasis is a neglected tropical disease with endemic foci in Cameroon. Epidemiological data on schistosomiasis in pregnancy are scarce in the country. This study describes the prevalence, diversity and factors associated with schistosomiasis in pregnant women in Njombe-Penja where schistosomiasis was first reported in 1968. Methodology: Two hundred and eighty-two (282) pregnant women were enrolled at first antenatal consultation between April and December 2016. A questionnaire was used to document socio-economic and obstetric information. Stool and terminal urine samples were collected and analysed using Kato-Katz/Formol-Ether concentration techniques and centrifugation methods respectively. Haemoglobin concentration was measured from finger prick blood, using an URIT®-12 electronic haemoglobinometer. Bivariate and logistic regression were used for statistical analyses with Epi-Info version 7.2.1.0. Statistical significance level was set at 0.05. Results: The overall prevalence of schistosomiasis was 31.91%. Schistosoma guineensis, S. haematobium and S. mansoni infections were found in 0.35% (n = 1), 4.96% (n = 14) and 28.01% (n = 79) of participants, respectively. Co-infection with two species of Schistosoma was found in 4.44% of these women. The prevalence of this disease was significantly higher in younger women (≤ 20 years old) and among residents of Njombe. All S. haematobium infected women were anemic and infection was associated with significantly lower haemoglobin levels (p = 0.02). Conclusion: The prevalence of schistosomiasis is high among pregnant women in Njombe-Penja, with some adverse effects on blood levels. Three Schistosoma species were found. Female of childbearing age should be considered for mass drug administration.

Parents’ Descriptions of Neonatal Palliation as a Treatment Option Prior to Periviable Delivery

Background and Hypothesis: During periviable deliveries, parents are confronted with overwhelming and challenging decisions, about which they may know little. This study aimed to explore qualitatively the language that mothers and important others (IOs) utilize when discussing palliation, or ‘comfort care,’ as a treatment option in the context of periviability. Project Methods: We prospectively recruited pregnant women (and designated IOs) admitted to labor and delivery for a threatened periviable delivery (22-25 weeks GA) at two hospitals between September 2016 and January 2018. Using a semi-structured interview guide, we explored participants’ perceptions of palliation and neonatal treatment options. Women were asked items such as, “How was the choice of resuscitation presented to you?” and “What were the options presented?” Research assistants developed a codebook for the interview transcripts, and NVivo 12 was used for qualitative analysis. Results: Thirty women and 16 IOs were recruited in total. Participants’ descriptions of palliation fell into five broad categories – ‘doing nothing,’ ‘not resuscitating,’ ‘withdrawal of care,’ ‘implicit comfort care,’ and ‘explicit comfort care.’ The majority of parents perceived comfort care not as a distinct treatment option, but rather as the absence of treatment. Several barriers to the comprehension of comfort care were observed, including subjects’ unfamiliarity with the terminology or the inability to remember its explanation during antenatal consultation. Parents described comfort care with either neutral or negative connotations, and even those parents able to discuss the concept neutrally chose resuscitation as their preferred treatment option. Conclusion and Potential Impact: This study revealed that many parents facing periviable delivery may lack understanding of comfort care as a neonatal treatment option. These parental perceptions highlight the need to improve counseling efforts in order to maximize parents’ informed decision-making.