BACKGROUND: When medically indicated, caesarean section (CS) can be a life-saving intervention for mothers and their newborns. This study assesses the prevalence of CS and its associated factors, focussing on inequalities between rural and urban areas in Nigeria.
METHODS: We disaggregated the Nigeria Demographic and Health Survey 2018 and performed analyses separately for Nigeria\'s overall, rural, and urban residences. We summarised data using frequency tabulations and identified factors associated with CS through multivariable logistic regression analysis.
RESULTS: CS prevalence was 2.7% in Nigeria (overall), 5.2% in urban and 1.2% in rural areas. The North-West region had the lowest prevalence of 0.7%, 1.5% and 0.4% for the overall, urban and rural areas, respectively. Mothers with higher education demonstrated a greater CS prevalence of 14.0% overall, 15.3% in urban and 9.7% in rural residences. Frequent internet use increased CS prevalence nationally (14.3%) and in urban (15.1%) and rural (10.1%) residences. The southern regions showed higher CS prevalence, with the South-West leading overall (7.0%) and in rural areas (3.3%), and the South-South highest in urban areas (8.5%). Across all residences, rich wealth index, maternal age ≥ 35, lower birth order, and ≥ eight antenatal (ANC) contacts increased the odds of a CS. In rural Nigeria, husbands\' education, spouses\' joint healthcare decisions, birth size, and unplanned pregnancy increased CS odds. In urban Nigeria, multiple births, Christianity, frequent internet use, and ease of getting permission to visit healthcare facilities were associated with higher likelihood of CS.
CONCLUSIONS: CS utilisation remains low in Nigeria and varies across rural-urban, regional, and socioeconomic divides. Targeted interventions are imperative for uneducated and socioeconomically disadvantaged mothers across all regions, as well as for mothers in urban areas who adhere to Islam, traditional, or \'other\' religions. Comprehensive intervention measures should prioritise educational opportunities and resources, especially for rural areas, awareness campaigns on the benefits of medically indicated CS, and engagement with community and religious leaders to promote acceptance using culturally and religiously sensitive approaches. Other practical strategies include promoting optimal ANC contacts, expanding internet access and digital literacy, especially for rural women (e.g., through community Wi-Fi programs), improving healthcare infrastructure and accessibility in regions with low CS prevalence, particularly in the North-West, and implementing socioeconomic empowerment programs, especially for women in rural areas.

Gravid uterine torsion less than 45 degrees is a common phenomenon of the third trimester. Torsion greater than 45 degrees represents a rare, pathologic, and obstetric emergency. The rotation of the uterus on a longitudinal plane can result in vascular compromise, and it has potential for catastrophic maternal-fetal complications. We report the case of a 22-year-old G3P1011, third pregnancy with history of one full-term live newborn, one spontaneous abortion, and presented at 38 weeks gestation with complaints of abdominal pressure and recurrent transverse fetal presentation. She underwent an external cephalic version (ECV), which resulted in fetal distress necessitating an emergency cesarean section. After successful delivery of the live newborn, an inspection of the uterus identified a uterine torsion of 180 degrees with delivery through a posterior hysterotomy incision. She had no postoperative complications and carried a subsequent pregnancy to term that was delivered via repeat cesarean section five years later. Gravid uterine torsion should be included in the differential diagnosis for patients presenting with abdominal pain and fetal intolerance to labor. A higher suspicion should be held for patients with a known history of uterine abnormalities or those having undergone an ECV. Our case also highlights a safe repeat cesarean section after this rare complication and brief narrative review of existing literature on this rare obstetrical emergency.

BACKGROUND: The rates of maternal and neonatal deaths in Madagascar are among the highest in the world. In response to a request for additional training from obstetrical care providers at the Ambanja district hospital in north-eastern Madagascar, a partnership of institutions in Switzerland and Madagascar conducted innovative training on respectful emergency obstetric and newborn care using e-learning and simulation methodologies. The training focused on six topics: pre-eclampsia, physiological childbirth, obstetric maneuvers, postpartum hemorrhage, maternal sepsis, and newborn resuscitation. Cross-cutting themes were interprofessional communication and respectful patient care. Ten experienced trainers participated in an e-training-of-trainers course conducted by the Swiss partners. The newly-trained trainers and Swiss partners then jointly conducted the hybrid remote/in-person training for 11 obstetrical care providers in Ambanja.
METHODS: A mixed methods evaluation was conducted of the impact of the training on participants\' knowledge and practices. Trainees\' knowledge was tested before, immediately after, and 6 months after the training. Focus group discussions were conducted to elicit participants\' opinions about the training, including the content and pedagogical methods.
RESULTS: Trainees\' knowledge of the six topics was higher at 6 months (with an average of 71% correct answers) compared to before the training (62%), although it was even higher (83%) immediately after the training. During the focus group discussions, participants highlighted their positive impressions of the training, including its impact on their sense of professional effectiveness. They reported that their interprofessional relationships and focus on respectful care had improved. Simulation, which was a new methodology for the participants native to Madagascar, was appreciated for its engaging and active format, and they enjoyed the hybrid delivery of the training. Participants (including the trainers) expressed a desire for follow-up engagement, including additional training, and improved access to more equipment.
CONCLUSIONS: The evaluation showed improvements in trainees\' knowledge and capacity to provide respectful emergency care to pregnant women and newborns across all training topics. The hybrid simulation-based training method elicited strong enthusiasm. Significant opportunity exists to expand the use of hybrid onsite/remote simulation-based training to improve obstetrical care and health outcomes for women and newborns in Madagascar and elsewhere.

BACKGROUND: In 2016, the WHO regional office for Europe prepared a manual for conducting routine facility based individual near miss case review cycle. This study evaluates the effectiveness of the individual near miss case review (NMCR) cycle in improving quality of emergency obstetric care and maternal outcome in Keren hospital.
METHODS: An interrupted time series design was used to achieve the objectives of this study. Monthly data on women with potentially life-threatening conditions (PLTCs) admitted between April 2018 and October 2022 (i.e. 33 months pre-implementation and 22 months post-implementation) were collected from medical records. Segmented regression analysis was used to assess the intervention\'s effect on three process and outcome measures, namely, SMO, delayed care, and substandard care. The intervention was expected a priori to show immediate improvements without time-lag followed by gradual increment in slope. Segmented regression analyses were performed using the \"itsa\' command in STATA.
RESULTS: During the entire study period, 4365 women with potentially life threatening conditions were identified. There was a significant reduction in the post-implementation period in the proportion of mothers with PLTC who experienced SMO (- 8.86; p <  0.001), delayed care (- 8.76; p <  0.001) and substandard care (- 5.58; p <  0.001) compared to pre-implementation period. Results from the segmented regression analysis revealed that the percentage of women with SMO showed a significant 4.75% (95% CI: - 6.95 to - 2.54, p <  0.001) reduction in level followed by 0.28 percentage points monthly (95% CI: - 0.37 to - 0.14, p <  0.001) drop in trend. Similarly, a significant drop of 3.50% (95% CI: - 4.74 to - 2.26, p <  0.001) in the level of substandard care along with a significant decrease of 0.21 percentage points (95% CI: - 0.28 to - 0.14, p < 0.001) in the slope of the regression line was observed. The proportion of women who received delayed care also showed a significant 7% (95% CI: - 9.28 to - 4.68, p < 0.001) reduction in post-implementation level without significant change in slope.
CONCLUSIONS: Our findings suggest that the WHO individual NMCR cycle was associated with substantial improvements in quality of emergency obstetric care and maternal outcome. The intervention also bears a great potential for scaling-up following the guidance provided in the WHO NMCR manual.

Background Multidisciplinary simulation training in the management of acute obstetric emergencies has the potential to reduce both maternal and perinatal morbidity. It is a valuable tool that can be adapted for targeted audiences of different specialities at all experience levels from medical students to senior consultants. Methods In this study, pre- and post-course questionnaires of learners with varying levels of clinical experience from Obstetrics and Gynaecology (O&G), Anaesthesia, Neonatology, Emergency Medicine, midwifery, and nursing who undertook two simulation courses (namely the Combined Obstetrics Resuscitation Training course, CORE, and the CORE Lite), which comprised lectures and simulation drills with manikins and standardized patients, between 2015 and 2023 were compared. This also included a period when training was affected by the coronavirus disease 2019 (COVID-19) pandemic.  Results The results showed that both simulation courses increased confidence levels among all learners in the management of obstetric emergencies.  Pre-course, participants were most confident in the management of neonatal resuscitation and severe pre-eclampsia, followed by postpartum haemorrhage. They were least confident in the management of vaginal breech delivery, uterine inversion, and twin delivery. Post-course, participants were most confident in the management of neonatal resuscitation and shoulder dystocia, followed by postpartum haemorrhage. They were least confident in the management of uterine inversion and maternal sepsis, followed by vaginal breech delivery and twin delivery. Whilst we saw a huge improvement in confidence levels for all obstetric emergencies, the greatest improvement in confidence levels was noted in vaginal breech delivery, twin delivery, and uterine inversion. Conclusion The simulation courses were effective in improving the confidence in the management of obstetric emergencies. While it may be difficult to measure the improvement in clinical outcomes as a result of simulation courses alone, the increase in confidence levels of clinicians can be used as a surrogate in measuring their preparedness in facing these emergency scenarios.

Living conditions and other factors in urban unplanned settlements present unique challenges for improving maternal and newborn health (MNH), yet MNH inequalities associated with such challenges are not well understood. This study examined trends and inequalities in coverage of MNH services in the last 20 years in unplanned and planned settlements of Lusaka City, Zambia. Geospatial information was used to map Lusaka\'s settlements and health facilities. Zambia Demographic Health Surveys (ZDHS 2001, 2007, 2013/2014, and 2018) were used to compare antenatal care (ANC), institutional delivery, and Cesarean section (C-section) coverage, and neonatal mortality rates between the poorer 60% and richer 40% households. Health Management Information System (HMIS) data from 2018 to 2021 were used to compute service volumes and coverage rates for ANC1 and ANC4, and institutional delivery and C-sections by facility level and type in planned and unplanned settlements. Although the correlation is not exact, our data analysis showed close alignment; and thus, we opted to use the 60% poorer and 40% richer groups as a proxy for households in unplanned versus planned settlements. Unplanned settlements were serviced by primary centers or first-level hospitals. ZDHS findings show that by 2018, at least one ANC visit and institutional delivery became nearly universal throughout Lusaka, but early and four or more ANC visits, C-sections, and neonatal mortality rates remained worse among poorer than richer women in ZDHS. In HMIS, ANC and institutional delivery volumes were highest in public facilities, especially in unplanned settlements. The volume of C-sections was much greater within facilities in planned than unplanned settlements. Our study exposed persistent gaps in timing and use of ANC and emergency obstetric care between unplanned and planned communities. Closing such gaps requires strengthening outreach early and consistently in pregnancy and increasing emergency obstetric care capacities and referrals to improve access to important MNH services for women and newborns in Lusaka\'s unplanned settlements.

BACKGROUND: Maternal Mortality (MM) in Nigeria is greatest in rural regions where access to emergency obstetric care (EmOC) services is hampered by a number of circumstances. Delay in obtaining prompt and proper care in obstetric emergency situations is a significant factor in poor mother outcomes. It is based on this premise that the researchers examined midwives\' knowledge and involvement regarding provision of emergency obstetric care in rural health facilities of Cross River State.
METHODS: The study adopted a cross-sectional descriptive design; a total population study of all ninety-four midwives who worked in maternal health care facilities in rural areas of CRS was utilised. Cross River state is a state in the South-South geopolitical zone of Nigeria, named after the Cross River, which passes through the state, located in the Niger Delta and occupies 20,156 square kilometers A self-developed and validated questionnaire was used for data collection. The instrument was pre-tested for reliability and result showed the reliability index ranging from 0.70 to 0.82. Quantitative data collected was analysed using Pearson product moment correlation test at 0.05 level of significance.
RESULTS: The research findings revealed midwives\' level of knowledge on emergency obstetric care in rural health facilities of CRS was significantly high, majority of the participants had provided some aspects of essential emergency obstetric care. The result of hypotheses revealed a significant relationship between knowledge and provision of EmOC amongst the midwives (P < .05).
CONCLUSIONS: Based on this, it was recommended that appropriate strategies such as on the job training\\ supportive supervision, refresher training and mentorship should also be ensured to enhance midwives\' capacity in emergency obstetric care. Finally, there is need for Community involvement/enlightenment, motivating traditional birth attendants and integrating them into maternal health care system.

UNASSIGNED: Caesarean section (CS) performed in an emergency can be life-saving for both the pregnant woman and her baby. In Nigeria, CS rates have been estimated to be 2.7% nationally, with the highest regional rate of 7.0% reported in the South-West of the country. Our objective in this facility-based retrospective cross-sectional study was to describe patterns and assess factors, obstetric indications, and outcomes of emergency CS in Lagos, Nigeria.
UNASSIGNED: Socio-demographic, travel, and obstetric data of pregnant women were extracted from case notes. Travel data was inputted in Google Maps to extract travel time from the pregnant women\' home to the hospital. Univariate, bivariate and multivariable logistic regression analyses were conducted.
UNASSIGNED: Of the 3,134 included pregnant women, 1,923 (61%) delivered via emergency CS. The odds of an emergency CS were significantly higher among women who were booked (OR=1.97, 95%CI 1.64-2.35), presented with obstructed labour (OR=2.59, 95%CI 1.68-3.99), pre-eclampsia/eclampsia (OR=1.67, 95%CI 1.08-2.56), multiple gestations (OR=2.71, 95%CI 1.72-4.28) and travelled from suburban areas (OR=1.43, 95%CI 1.15-1.78). There was an increasing dose-effect response between travel time to the hospital and emergency CS.
UNASSIGNED: Optimisation of CS rates requires a multi-pronged approach during pregnancy and childbirth, with particular emphasis on supporting pregnant women living in the suburbs.

UNASSIGNED: Medical disorders complicating pregnancy have recently emerged as the most common cause for maternal morbidity and mortality and it is important to predict mortality risk when they present in moribund state to emergency obstetric care so as to take and timely effective measures to prevent mortality.
UNASSIGNED: This prospective observational study was conducted over 6 months among pregnant and post-partum women with medical disorders who sought emergency obstetric care at a tertiary care hospital. Severity of morbidity was assessed using SOFA and APACHE II scores at admission.
UNASSIGNED: Of the 128 women, 87.5% were pregnant, and 12.5% were post-partum. Hypertensive disorders, cardiac disorders, neurological disorders and infective disorders were 24.2%, 22.6%, 14% and 9.4%, respectively. The optimal cut-off SOFA score was 2 (AUC = 0.739) with 66% sensitivity and 71% specificity and APACHE II score cut-off was 6 (AUC = 0.732) with a sensitivity of 60% and specificity of 78% in predicting severe maternal morbidity. The median scores of APACHE II and SOFA are 14 and 4, respectively, for non-survivors and for survivors it was 4 and 1.
UNASSIGNED: Hypertensive disorder was the most common medical disorder, but severity was high in cardiac disorder. SOFA and APACHE II scores are good predictors of morbidity and mortality risk.

BACKGROUND: Routine health facility data provides the opportunity to monitor progress in quality and uptake of health care continuously. Our study aimed to assess the reliability and usefulness of emergency obstetric care data including temporal and regional variations over the past five years in Tanzania Mainland.
METHODS: Data were compiled from the routine monthly district reports compiled as part of the health management information systems for 2016-2020. Key indicators for maternal and neonatal care coverage, emergency obstetric and neonatal complications, and interventions indicators were computed. Assessment on reliability and consistency of reports was conducted and compared with annual rates and proportions over time, across the 26 regions in of Tanzania Mainland and by institutional delivery coverage.
RESULTS: Facility reporting was near complete with 98% in 2018-2020. Estimated population coverage of institutional births increased by 10% points from 71.2% to 2016 to 81.7% in 2020 in Tanzania Mainland, driven by increased use of dispensaries and health centres compared to hospitals. This trend was more pronounced in regions with lower institutional birth rates. The Caesarean section rate remained stable at around 10% of institutional births. Trends in the occurrence of complications such as antepartum haemorrhage, premature rupture of membranes, pre-eclampsia, eclampsia or post-partum bleeding were consistent over time but at low levels (1% of institutional births). Prophylactic uterotonics were provided to nearly all births while curative uterotonics were reported to be used in less than 10% of post-partum bleeding and retained placenta cases.
CONCLUSIONS: Our results show a mixed picture in terms of usefulness of the District Health Information System(DHIS2) data. Key indicators of institutional delivery and Caesarean section rates were plausible and provide useful information on regional disparities and trends. However, obstetric complications and several interventions were underreported thus diminishing the usefulness of these data for monitoring. Further research is needed on why complications and interventions to address them are not documented reliably.