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Complication recognition and management during childbirth is a critical requirement for reducing maternal and perinatal mortality to meet the UN’s Sustainable Development Goals.
Building successful and sustainable solutions requires an understanding of the complexity across different layers of the health care ecosystem, including patient preferences, birth attendant behaviors, the context at a given health facility, and the accountability and responsiveness of a larger health system.
This short report unpacks the complexity of five life-saving, facility-based interventions observed during the BetterBirth trial: Referral, cesarean deliveries, antibiotic use, neonatal resuscitation, and oxytocin administration. We highlight process-related findings, such as which groups received the intervention, and health outcomes related findings, such as which groups who received the intervention had the great risk of mortality. The following are our main findings:
Low referral rates
Referral rates for newborns were concerningly low: only 1.6% of newborns were referred to higher-level facilities. The majority of newborns who ultimately died were never referred to higher-level care. Twins and older women were more likely to be referred (either in utero or after birth), while only ~4% of other high-risk groups such as preterm babies and low birth weight babies were ever referred.
Asphyxia was the predominant cause of death both among those referred and not referred in our sub-study population. Obstructed labor was a major cause of stillbirth among women who were never referred, which may be indicative of a too-low referral and cesarean rate. Non-referred, neonatal deaths that occurred at home were mainly caused by sepsis.
Low cesarean rates
Cesarean rates in the study were 1.8%. Almost all cases requiring cesarean were referred (91%), despite over half of the study facilities reporting to have cesarean capability. Among the 247 cases where a cesarean occurred at a primary-level facility, almost all took place between the hours of 8 a.m. and 2 p.m. Those that arrived in the evening or night had to wait up to 13 hours to deliver.
Cesarean rarely performednon stillbirths
Only five stillbirths were reported among the 2,481 cesarean deliveries in the study.
Varied antibiotic use
Antibiotics were given to 14.9% of women and 3.6% of newborns in our direct observation study. Maternal mortality (within seven days) was similar for women who received antibiotics versus those who did not. Among newborns who died within seven days of birth and who did not receive antibiotics around the time of birth, ~25% died of infection, which indicates that recognition and treatment of infection may be insufficient.
Rates of neonatal resuscitation were similar for high risk groups
In our directly observed cohort, we found that 6.4% of newborns received ventilation with a bag and mask. High risk groups, such as preterm newborns, received resuscitation at only slightly higher rates (6.9%).
Neonatal survival following resuscitation
We found that 80% of newborns who received bag and mask resuscitation survived at least the first week of life. Among those who were resuscitated but died, the primary causes of death were asphyxia and complications of prematurity (e.g., lung underdevelopment). Among those who did not receive resuscitation (n=62) but died within seven days of birth, the primary causes of death were asphyxia (39%), complications of prematurity (21%), and sepsis (19%).
Intrapartum oxytocin used during most deliveries, despite the danger
Intrapartum oxytocin can shorten labor, but careful monitoring is needed to avoid fetal distress. At baseline, intrapartum oxytocin was administered to 79% of women to augment labor despite <1% use of partograph, which is used to monitor and document fetal heart rate and contraction patterns.
Unmonitored use of intrapartum oxytocin increases the need for neonatal resuscitation
In this setting, intrapartum oxytocin use is associated with increased neonatal resuscitation.
Overall, we documented significant gaps in the treatment of complications during the BetterBirth study. These gaps give us direction in where to invest future research and intervention in complications management moving forward.