Search results
Found 9277 matches for
Nuffield Department of Women's & Reproductive Health sits within the Medical Sciences Division of the University of Oxford. The department encompasses multi-disciplinary research across four overarching themes; Cancer, Global Health, Maternal & Fetal Health and Reproductive Medicine & Genetics
What is the safest mode of birth for extremely preterm breech singleton infants who are actively resuscitated? A systematic review and meta-analyses
Background: The safest delivery mode of extremely preterm breech singletons is unknown. Objectives: To determine safest delivery mode of actively resuscitated extremely preterm breech singletons. Search strategy: We searched Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL and ClinicalTrials.gov from January 1994 to May 2017. Selection criteria: We included studies comparing outcomes by delivery mode in actively resuscitated breech infants between 23 +0 and 27 +6 weeks. Data collection and analysis: We synthesised data using random effects, generated odds ratios, 95% confidence intervals and number-needed-to-treat (NNT). Our primary outcomes were death (neonatal, before discharge, or by 6 months) and severe intraventricular haemorrhage (grades III/IV), stratified by gestational age (23 +0 –24 +6 , 25 +0 –26 +6 , 27 +0 –27 +6 weeks). Main results: We included 15 studies with 12 335 infants. We found that caesarean section was associated with a 41% decrease in odds of death between 23 +0 and 27 +6 weeks [odds ratio (OR) 0.59, 95% CI 0.36–0.95, NNT 8], with the greatest decrease at 23 +0 –24 +6 weeks (OR 0.58, 95% CI 0.44–0.75, NNT 7). The OR at 25 +0 –26 +6 and 27 +0 –27 +6 weeks were 0.72 (95% CI 0.34–1.52) and 2.04 (95% CI 0.20–20.62), respectively. We found that caesarean section was associated with 49% decrease in odds of severe intraventricular haemorrhage between 23 +0 and 27 +6 weeks (OR 0.51, 95% CI 0.29–0.91, NNT 12), whereas the OR at 25 +0 –26 +6 and 27 +0 –27 +6 was 0.29 (95% CI 0.07–1.12) and 0.91 (95% CI 0.27–3.05), respectively. Conclusions: Caesarean section was associated with reductions in the odds of death by 41% and of severe intraventricular haemorrhage by 49% in actively resuscitated breech singletons < 28 weeks of gestation. The data are mostly observational, which may be inherently biased, and scarce on other morbidities, necessitating thorough discussion between parents and clinicians. Tweetable abstract: Caesarean section associated with lower odds of death and severe intraventricular haemorrhage in actively resuscitated breech singletons <28 weeks.
Co-designing the implementation of a rural health systems-strengthening rheumatic heart disease program with remote First Nations Australian communities using Theory of Change.
BACKGROUND: Rheumatic heart disease (RHD) is highly prevalent and under-detected in remote First Nations Australian communities. Rural communities face severe health workforce shortages that impact negatively on health outcomes. Task-sharing using local healthcare workers, trained to screen for active RHD cases (using handheld ultrasound with remote support from experts), has been proposed as a means of improving early detection whilst also strengthening referral pathways. Implementing new models of care within remote communities, however, requires local knowledge, cultural and operational adaptation, whilst ensuring consistency and quality assurance across multiple sites. This study aimed to co-design local implementation strategies for an RHD active case finding program with five remote communities and explain how and why the task-sharing program might lead to improved health outcomes. METHODS: A qualitative study using a Theory of Change approach and 'yarning' methods, was conducted with five remote First Nations Australian communities. We used a combination of participant observation, extensive field notes over sequential visits to each site, supplemented with document analysis to inform co-design of Theories of Change for each community. Data were curated using NVivo software and analysed using Powell's refined compilation of implementation strategies framework. RESULTS: Through the co-design process, a total of 24 locally tailored implementation strategies were identified. All sites identified the need for a positive implementation environment, including recognition of local healthcare workers through positive messaging and celebratory events for achieving key training milestones. Other key themes included the importance of opportunistic RHD screening, and the integration of local languages during both training and screening. Five locally adapted versions of the Theory of Change were co-designed to include planned outcomes, assumptions, causal mechanisms, and indicators for the program at each community. CONCLUSIONS: Our study identified implementation strategies and Theories of Change for the training and screening aspects of a new model of care for RHD screening in five remote First Nation Australian communities. These findings will be used to support future program evaluation and exploration the mechanisms by which the RHD screening program achieves its outcomes.
Identification of heart failure subtypes using transformer-based deep learning modelling: a population-based study of 379,108 individuals.
BACKGROUND: Heart failure (HF) is a complex syndrome with varied presentations and progression patterns. Traditional classification systems based on left ventricular ejection fraction (LVEF) have limitations in capturing the heterogeneity of HF. We aimed to explore the application of deep learning, specifically a Transformer-based approach, to analyse electronic health records (EHR) for a refined subtyping of patients with HF. METHODS: We utilised linked EHR from primary and secondary care, sourced from the Clinical Practice Research Datalink (CPRD) Aurum, which encompassed health data of over 30 million individuals in the UK. Individuals aged 35 and above with incident reports of HF between January 1, 2005, and January 1, 2018, were included. We proposed a Transformer-based approach to cluster patients based on all clinical diagnoses, procedures, and medication records in EHR. Statistical machine learning (ML) methods were used for comparative benchmarking. The models were trained on a derivation cohort and assessed for their ability to delineate distinct clusters and prognostic value by comparing one-year all-cause mortality and HF hospitalisation rates among the identified subgroups in a separate validation cohort. Association analyses were conducted to elucidate the clinical characteristics of the derived clusters. FINDINGS: A total of 379,108 patients were included in the HF subtyping analysis. The Transformer-based approach outperformed alternative methods, delineating more distinct and prognostically valuable clusters. This approach identified seven unique HF patient clusters characterised by differing patterns of mortality, hospitalisation, and comorbidities. These clusters were labelled based on the dominant clinical features present at the initial diagnosis of HF: early-onset, hypertension, ischaemic heart disease, metabolic problems, chronic obstructive pulmonary disease (COPD), thyroid dysfunction, and late-onset clusters. The Transformer-based subtyping approach successfully captured the multifaceted nature of HF. INTERPRETATION: This study identified seven distinct subtypes, including COPD-related and thyroid dysfunction-related subgroups, which are two high-risk subgroups not recognised in previous subtyping analyses. These insights lay the groundwork for further investigations into tailored and effective management strategies for HF. FUNDING: British Heart Foundation, European Union - Horizon Europe, and Novo Nordisk Research Centre Oxford.
Contraceptive strategies for reducing the risk of reproductive cancers
Reproductive cancers, encompassing various malignancies like endometrial, ovarian, cervical cancer, and gestational trophoblastic neoplasia, pose a significant global health burden. Understanding their patterns is vital for effective prevention and management. Contraceptives show a protective effect against some of these cancers. This clinical guidance document aims to elucidate the disease burden of reproductive cancers and the evidence supporting contraceptive methods in prevention and management. Regional disparities in incidence and mortality highlight the urgent need for targeted interventions, particularly in low-resource settings. Healthcare providers must weigh individual risk profiles and medical eligibility criteria when discussing contraceptive options. Enhanced health literacy through direct patient education is essential for leveraging low-cost behavioral interventions to mitigate reproductive cancer risks.
A non‐inferiority analysis of hemoglobin levels in postpartum IUD users in Bangladesh
AbstractObjectiveThe objective of this study was to compare postpartum hemoglobin (Hb) between postpartum intrauterine device (PPIUD) and non‐PPIUD users.MethodsA sample of 3697 postpartum women (475 PPIUD users, 3222 non‐PPIUD users) from 5 tertiary referral hospitals in Bangladesh were assessed at multiple time points between 6 weeks and 12 months postpartum. Non‐inferiority linear regression analysis compared changes in Hb levels at 29–52 weeks postpartum between the two groups. Non‐inferiority was declared if the lower 95% confidence interval of the estimated difference in Hb change since delivery between PPIUD and non‐PPIUD users was greater than −0.05 g/dl.ResultsAt approximately 9 months postpartum, 276 women in the PPIUD group (58.1%) and 1086 women in the comparison group (33.7%) attended follow‐up. In total, 57.9% of PPIUD users and 61.0% of non‐PPIUD users had taken iron supplementation. Change in Hb was 0.02 g/dl (95% CI: −0.16, 0.19) higher in the PPIUD users than the comparison group. The lower limit of the 95% CI was greater than −0.05 g/dl, providing good evidence that PPIUD users were non‐inferior to the comparison group in their Hb levels.ConclusionIn the presence of offering iron supplementation, and an uptake of just over 60%, no difference in anemia was observed between the PPIUD and control group.
Impact of immediate postpartum insertion of TCu380A on the quantity and duration of lochia discharges in Tanzania
Abstract Background The insertion of Intrauterine Contraceptive Device (PPIUD) for the purpose of contraception immediately after delivery is becoming popular in countries where the use of IUD for contraception has been extremely low. Since 2015, Tanzania implemented the initiative by the International Federation of Gynecology and Obstetrics (FIGO) to institutionalize PPIUD. As a result of capacity building and information delivery under the initiative, there have been increased uptake of the method. Working in this context, the focus of the study was to generate evidence on the effect of TCu380A IUD on amount and duration of lochia and equip service providers with evidence-based knowledge which can help them in counselling their PPIUD clients. Objective Establish impact of postpartum TCu380A on amount and duration of lochia. Methods A prospective cohort study of delivered women in two teaching hospitals in Tanzania with immediate insertion of TCu380A or without use of postpartum contraception in 2018. TCu380A models; Optima (Injeflex Co. Brazil) and Pregna (Pregna International, Chakan, India) were used. Follow-up was done by weekly calls and examination at 6th week. Lochia was estimated by Likert Scale 0–4 relative to the amount of lochia on the delivery day. An estimated 250 women sample (125 each group) would give 80% power to detect a desired 20% difference in the proportion of women with prolonged lochia discharges among the Exposed and Unexposed groups. Data analysis was by SPSS. Results Two hundred sixty women were analysed, 127 Exposed and 133 Unexposed. Medical complaints were reported by 41 (28.9%) Exposed and 37 Unexposed (27.8%), p = 0.655. Lack of dryness by end of 6th week was to 31 (23.3%) Exposed and 9 (7.1%) Unexposed, p < 0.001. Exposed had higher weekly mean lochia scores throughout with the difference most marked in 5th week (3.556 Versus 2.039, p < 0.001) and 6th week (1.44 Versus 0.449, p<0.001). Conclusion PPIUD is associated with increased amount of lochia and slows progression to dryness within 6 weeks of delivery. The implications of PPIUD clients’ needs to be informed about the possibility of delayed dryness of lochia at time of counseling are discussed.
Evaluating the impact of female community health volunteer involvement in a postpartum family planning intervention in Nepal: A mixed-methods study at one-year post-intervention
Introduction This is a one-year post-intervention study following an initiative to provide orientation to female community health volunteers (FCHVs) on postpartum family planning in Nepal. In light of positive results in the earlier post-intervention study, this study was designed to provide a more long-term perspective on sustainability by assessing the effect at one-year post-intervention. Methods This mixed-methods study was conducted in January 2020 in Morang district, Nepal. We collected quantitative data from a knowledge assessment of FCHVs who had participated in the intervention on postpartum family planning, data on their community-based counseling coverage and through interviews with postpartum mothers in two selected hospitals. Qualitative data were collected through six key informant interviews with health providers and four focus group discussions with FCHVs involved in the intervention. We performed descriptive and multivariate analyses for quantitative data and thematic analysis for qualitative data. Results In total, 206 FCHVs participated in the one-year post-intervention study with significant improvement in knowledge of postpartum family planning as compared to pre-intervention period. The adjusted odds ratios (AOR) for knowledge of the 5 key messages on postpartum family planning as compared to the pre-intervention period included 1) knowledge on postpartum family planning can be used immediately after birth (AOR = 18.1, P<0.001), 2) postpartum intra-uterine device (PPIUD) can provide protection up to 12 years (AOR = 2.9, P = 0.011), 3) mothers who undergo cesarean section can use PPIUD (AOR = 2.3, P<0.001), 4) PPIUD can be inserted immediately after birth (AOR = 6.2, P <0.001), and 5) women should go for follow-up immediately if the IUD strings are seen outside vulva (AOR = 2.0, P = 0.08). The FCHVs answering 4 or more questions correctly was 10 times higher (AOR = 10.1, P<0.001) at one-year post-intervention, whereas it was 25 times higher at immediate-post-test (AOR = 25.1, p<0.001) as compared to pre-intervention phase. The FCHVs had counseled 71% of the pregnant women (n = 538) within their communities at one-year post-intervention. The postpartum mothers in hospitals had a 2 times higher odds of being counseled by FCHVs during their pregnancy at one-year post-intervention (AOR = 1.8, P = 0.039) than in pre-intervention phase. The qualitative findings suggested a positive impression regarding the FCHV’s involvement in postpartum family planning counseling in the communities, however, supervision and monitoring over a longer term was identified as a key challenge and that may influence sustainability of community-based and hospital-based postpartum family planning services. Conclusion The FCHVs’ knowledge and community-based activities on postpartum family planning remained higher than in the pre-intervention. However, it declined when compared to the immediate post-intervention period. We propose regular supervision and monitoring of the work of the FCHVs to sustain progress.
Improving post-partum family planning services provided by female community health volunteers in Nepal: a mixed methods study
Abstract Background Family planning services in the post-partum period, termed post-partum family planning (PPFP) is critical to cover the unmet need for contraception, especially when institutional delivery rates have increased. However, the intention to choose PPFP methods such as post-partum intrauterine devices (PPIUD) remains low in countries such as Nepal. Community health workers such as Female Community Health Volunteers (FCHVs) could play an important role in improving the service coverage of PPFP in Nepal. However, their knowledge of PPFP and community-based services related to PPFP remain unclear. This study aims to assess the effect on community-based PPFP services by improving FCHV’s knowledge through orientation on PPFP. Methods We conducted this mixed-methods study in Morang District in Nepal. The intervention involved orientation of FCHVs on PPFP methods. We collected quantitative data from three sources; via a survey of FCHVs that assessed their knowledge before and after the intervention, from their monthly reporting forms on counseling coverage of women at different stages of pregnancy from the communities, and by interviewing mothers in their immediate post-partum period in two selected hospitals. We also conducted six focus group discussions with the FCHVs to understand their perception of PPFP and the intervention. We performed descriptive and multivariable analyses for quantitative results and thematic analysis for qualitative data. Results In total, 230 FCHVs participated in the intervention and their knowledge of PPFP improved significantly after it. The intervention was the only factor significantly associated with their improved knowledge (adjusted odds ratio = 24, P < 0.001) in the multivariable analysis. FCHVs were able to counsel 83.3% of 1872 mothers at different stages of pregnancy in the communities. In the two hospitals, the proportion of mothers in their immediate post-partum period whom reported they were counseled by FCHVs during their pregnancy increased. It improved from 7% before the intervention to 18.1% (P < 0.001) after the intervention. The qualitative findings suggested that the intervention improved their knowledge in providing PPFP counseling. Conclusion The orientation improved the FCHV’s knowledge of PPFP and their community-based counseling. Follow-up studies are needed to assess the longer term effect of the FCHV’s role in improving community-based PPFP services.
A one-year cohort study of complications, continuation, and failure rates of postpartum TCu380A in Tanzania
Abstract Background Less than 1% of married women in Tanzania use an Intrauterine Contraceptive Device (IUD) for contraception. An initiative by the International Federation of Gynecology and Obstetrics (FIGO) has been in progress since 2015 resulting in escalated method uptake in implementing hospitals. This study investigates failure rate, complications, and risk factors for one-year continuation of TCu380A IUD when used for immediate postpartum contraception under the initiative in Tanzania. Methodology A prospective cohort study of women who had TCu380A insertion within 48 h of delivery in 6 hospitals in Tanzania between 1st December 2017 and 18th April 2018 was conducted. Face to face post insertion interviews were made with 1114 clients before discharge and later through phone calls up to the beginning of 13th month postpartum. Postpartum Intrauterine Device (PPIUD) continuation status, complications, duration of time they stayed with the IUD and the currently used method if PPIUD was discontinued were enquired. The outcome variable was PPIUD continuation at one year of IUD insertion. Data were analyzed using Statistical Product and Service Solutions software (SPSS) for Windows version 20 (IBM SPSS Statistics, Chicago, IL, USA). Results In total 511(45.8%)clients had consented and availed to complete the one-year follow-up. Out of these, 440 still had IUD, giving a one-year continuation rate of 86.1%. Most (63%) IUD discontinuations occurred in the period between 7th week and 6 months of insertion. One-year method expulsion rate was 2.1%. There was one reported pregnancy that gives a method failure rate of about 2 per 1000. The independent risk factors in favor of method continuation at one year were absence of medical or social problem, being a youth (16–24 years), and delivery by Cesarean section. Conclusions The continuation rate when CuT380A is used for immediate postpartum contraception is high, with low complication and failure rates. Some medical and social factors are important for method continuation, hence the need to consider in training, counselling and advocacy.
Prevalence of Postpartum Family Planning Service Coverage in Selected Referral Facilities of Nepal
Introduction: Nepal Society of Obstetricians and Gynecologists jointly with the Nepalese governmentand with the support from the International Federation of Obstetrics and Gynecology hasimplemented an initiative to institutionalize postpartum family planning services in selected majorreferral facilities of Nepal to address the gap of low uptake of postpartum family planning in Nepal.The aim of the study is to find the prevalence of the service coverage of postpartum contraception inthe selected facilities. Methods: A descriptive cross-sectional study was conducted in seven major referral facilities acrossNepal. Data were collected from the hospital records of all women who delivered in these facilitiesbetween October 2018 and March 2019. Ethical approval for this study was obtained from NepalHealth Research Council. Data analysis was done with SPSS version 23. Results: Among the 29,072 deliveries from all the facilities, postpartum family planning counselingcoverage was 27,301 (93.9%). The prevalence of uptake of Postpartum Intrauterine Device is 1581(5.4%) and female sterilization is 1830 (6.3%). In total 11387 mothers (52.2%) had the intention tochoose a postpartum family planning method. However, 36% of mothers neither used nor had theintention to choose a postpartum family planning method. Conclusions: The coverage of Postpartum Intrauterine Device counseling service coverage in Nepal ishigher in 2018 as compared to 2016-2017 and in other countries implementing Postpartum IntrauterineDevice initiatives. However, the prevalence of service coverage of immediate Postpartum FamilyPlanning methods, mainly Postpartum Intrauterine Device in 2018 is lower in Nepal as compared to2016-2017, and other countries implementing Postpartum Intrauterine Device initiative. More effortsare needed to encourage mothers delivering in the facilities to use the postpartum family planningmethod.