分娩时是否遵循基于证据的实践可以预防围产期死亡？印度北方邦 3274 例分娩的事后分析。
Does adherence to evidence-based practices during childbirth prevent perinatal mortality? A post-hoc analysis of 3,274 births in Uttar Pradesh, India.
机构信息
Ariadne Labs at Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
Division of Global Health Equity & Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
出版信息
BMJ Glob Health. 2020 Sep;5(9). doi: 10.1136/bmjgh-2019-002268.
BACKGROUND
Evidence-based practices that reduce childbirth-related morbidity and mortality are core processes to quality of care. In the BetterBirth trial, a matched-pair, cluster-randomised controlled trial of a coaching-based implementation of the WHO Safe Childbirth Checklist (SCC) in Uttar Pradesh, India, we observed a significant increase in adherence to practices, but no reduction in perinatal mortality.
METHODS
Within the BetterBirth trial, we observed birth attendants in a subset of study sites providing care to labouring women to assess the adherence to individual and groups of practices. We observed care from admission to the facility until 1 hour post partum. We followed observed women/newborns for 7-day perinatal health outcomes. Using this observational data, we conducted a post-hoc, exploratory analysis to understand the relationship of birth attendants' practice adherence to perinatal mortality.
FINDINGS
Across 30 primary health facilities, we observed 3274 deliveries and obtained 7-day health outcomes. Adherence to individual practices, containing supply preparation and direct provider care, varied widely (0·51 to 99·78%). We recorded 166 perinatal deaths (50·71 per 1000 births), including 56 (17·1 per 1000) stillbirths. Each additional practice performed was significantly associated with reduced odds of perinatal (OR: 0·82, 95% CI: 0·72, 0·93) and early neonatal mortality (OR: 0·78, 95% CI: 0·71, 0·85). Each additional practice as part of direct provider care was associated strongly with reduced odds of perinatal (OR: 0·73, 95% CI: 0·62, 0·86) and early neonatal mortality (OR: 0·67, 95% CI: 0·56, 0·80). No individual practice or single supply preparation was associated with perinatal mortality.
INTERPRETATION
Adherence to practices on the WHO SCC is associated with reduced mortality, indicating that adherence is a valid indicator of higher quality of care. However, the causal relationships between practices and outcomes are complex.
FUNDING
Bill & Melinda Gates Foundation.
TRIAL REGISTRATION DETAILS
ClinicalTrials.gov: NCT02148952; Universal Trial Number: U1111-1131-5647.
背景
降低分娩相关发病率和死亡率的循证实践是护理质量的核心流程。在 BetterBirth 试验中，我们在印度北方邦进行了一项基于匹配对、群组随机对照试验，以评估基于教练的 WHO 安全分娩清单（SCC）的实施对减少围产期死亡率的效果。我们发现实践的依从性显著增加，但围产期死亡率没有降低。
方法
在 BetterBirth 试验中，我们观察了一部分研究地点的分娩护理人员，以评估他们对个别实践和实践组的依从性。我们观察了从入院到产后 1 小时的护理过程。我们对观察到的妇女/新生儿进行了为期 7 天的围产期健康结局随访。利用这一观察数据，我们进行了事后、探索性分析，以了解分娩护理人员实践依从性与围产期死亡率之间的关系。
发现
在 30 家初级卫生保健机构中，我们观察了 3274 次分娩，并获得了 7 天的健康结局。个别实践（包括供应准备和直接提供者护理）的依从性差异很大（0.51 至 99.78%）。我们记录了 166 例围产期死亡（每 1000 例活产中有 50.71 例），包括 56 例（每 1000 例中有 17.1 例）死产。每增加一项实施的实践都与降低围产期（比值比[OR]：0.82，95%置信区间[CI]：0.72，0.93）和早期新生儿死亡率（OR：0.78，95%CI：0.71，0.85）的几率显著相关。作为直接提供者护理的一部分，每增加一项实践与降低围产期（OR：0.73，95%CI：0.62，0.86）和早期新生儿死亡率（OR：0.67，95%CI：0.56，0.80）的几率也显著相关。没有任何单一实践或单个供应准备与围产期死亡率相关。
解释
对世卫组织 SCC 上的实践的依从性与死亡率降低相关，这表明依从性是高质量护理的有效指标。然而，实践与结果之间的因果关系很复杂。
资金来源
比尔及梅琳达·盖茨基金会。
临床试验注册详情
ClinicalTrials.gov：NCT02148952；通用试验编号：U1111-1131-5647。
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