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  • 1.
    Gurung, Rejina
    et al.
    Golden Community, Jwagal, Lalitpur, Nepal.
    Jha, Anjani Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Pyakurel, Susheel
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Gurung, Abhishek
    Golden Community, Jwagal, Lalitpur, Nepal.
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Wrammert, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Jha, Bijay Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Paudel, Prajwal
    Anweshan, Lalitpur, Nepal.
    Rahman, Syed Moshfiqur
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Malla, Honey
    Golden Community, Jwagal, Lalitpur, Nepal.
    Sharma, Srijana
    Golden Community, Jwagal, Lalitpur, Nepal.
    Gautam, Manish
    Anweshan, Lalitpur, Nepal.
    Linde, Jorgen Erland
    Stavanger Univ Hosp, Dept Paediat, Stavanger, Norway.
    Moinuddin, Md
    ICDDR B, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Axelin, Anna
    Univ Turku, Turku, Finland.
    KC, Ashish
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Soc Publ Hlth Phys Nepal, Lalitpur, Nepal.
    Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN) - a stepped wedge cluster randomized controlled trial in public hospitals2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, article id 65Article in journal (Refereed)
    Abstract [en]

    Background: Each year, 2.2 million intrapartum-related deaths (intrapartum stillbirths and first day neonatal deaths) occur worldwide with 99% of them taking place in low- and middle-income countries. Despite the accelerated increase in the proportion of deliveries taking place in health facilities in these settings, the stillborn and neonatal mortality rates have not reduced proportionately. Poor quality of care in health facilities is attributed to two-thirds of these deaths. Improving quality of care during the intrapartum period needs investments in evidence-based interventions. We aim to evaluate the quality improvement packageScaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN)on intrapartum care and intrapartum-related mortality in public hospitals of Nepal.

    Methods: We will conduct a stepped wedge cluster randomized controlled trial in eight public hospitals with each having least 3000 deliveries a year. Each hospital will represent a cluster with an intervention transition period of 2months in each. With a level of significance of 95%, the statistical power of 90% and an intra-cluster correlation of 0.00015, a study period of 19months should detect at least a 15% change in intrapartum-related mortality. Quality improvement training, mentoring, systematic feedback, and a continuous improvement cycle will be instituted based on bottleneck analyses in each hospital. All concerned health workers will be trained on standard basic neonatal resuscitation and essential newborn care. Portable fetal heart monitors (Moyo (R)) and neonatal heart rate monitors (Neobeat (R)) will be introduced in the hospitals to identify fetal distress during labor and to improve neonatal resuscitation. Independent research teams will collect data in each hospital on intervention inputs, processes, and outcomes by reviewing records and carrying out observations and interviews. The dose-response effect will be evaluated through process evaluations.

    Discussion: With the global momentum to improve quality of intrapartum care, better understanding of QI package within a health facility context is important. The proposed package is based on experiences from a similar previous scale-up trial carried out in Nepal. The proposed evaluation will provide evidence on QI package and technology for implementation and scale up in similar settings.

  • 2. Gurung, Rejina
    et al.
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Berkelhamer, Sara
    Zhou, Hong
    Tinkari, Bhim Singh
    Paudel, Prajwal
    Malla, Honey
    Sharma, Srijana
    KC, Ashish
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    The burden of misclassification of antepartum stillbirth in Nepal2019In: BMJ Global Health, Vol. 4, no 6Article in journal (Refereed)
    Abstract [en]

    Background Globally, every year 1.1 million antepartum stillbirths occur with 98% of these deaths taking place in countries where the health system is poor. In this paper we examine the burden of misclassification of antepartum stillbirth in hospitals of Nepal and factors associated with misclassification.Method A prospective observational study was conducted in 12 hospitals of Nepal for a period of 6 months. If fetal heart sounds (FHS) were detected at admission and during the intrapartum period, the antepartum stillbirth (fetal death >=22 weeks prior labour) recorded in patient’s case note was recategorised as misclassified antepartum stillbirth. We further compared sociodemographic, obstetric and neonatal characteristics of misclassified and correctly classified antepartum stillbirths using bivariate and multivariate analysis.Result A total of 41 061 women were enrolled in the study and 39 562 of the participants’ FHS were taken at admission. Of the total participants whose FHS were taken at admission, 94.8% had normal FHS, 4.7% had abnormal FHS and 0.6% had no FHS at admission. Of the total 119 recorded antepartum stillbirths, 29 (24.4%) had FHS at admission and during labour and therefore categorised as misclassified antepartum stillbirths. Multivariate analysis performed to adjust the risk of association revealed that complications during pregnancy resulted in a threefold risk of misclassification (adjusted OR-3.35, 95% CI 1.95 to 5.76).Conclusion Almost 25% of the recorded antepartum stillbirths were misclassified. Improving quality of data is crucial to improving accountability and quality of care. As the interventions to reduce antepartum stillbirth differ, accurate measurement of antepartum stillbirth is critical.Trial registration number ISRCTN30829654.

  • 3.
    KC, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Axelin, Anna
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Tinkari, Bhim Singh
    Sunny, Avinash K
    Gurung, Rejina
    Coverage, associated factors, and impact of companionship during labor: A large-scale observational study in six hospitals in Nepal.2019In: Birth, ISSN 0730-7659, E-ISSN 1523-536XArticle in journal (Refereed)
    Abstract [en]

    BACKGROUND: Companionship at the time of birth is a nonclinical intervention that has been proven to improve the quality of intrapartum care. This study aims to evaluate the coverage, associated factors, and impact of companionship during labor at public hospitals in Nepal.

    METHODS: We conducted a cross-sectional observational study in six public hospitals in Nepal. The study was conducted from July 2018 to August 2018. Data were collected on sociodemographic, maternal, obstetric, and neonatal characteristics from patient case notes and through predischarge interviews. Coverage of companionship during labor and its association with intrapartum care was analyzed. Bivariate and multivariate analyses were done to assess the association between companionship during labor and demographic, obstetric, and neonatal characteristics.

    RESULTS: A total of 63 077 women participated in the study with 19% of them having a companion during labor. Women aged 19-24 years had 65% higher odds of having a companion during labor compared with women aged 35 years and older (aOR 1.65 [95% CI, 1.40-1.94]). Women who were from an advantaged ethnic group (Chhetri/Brahmin) had fourfold higher odds of having a companion than women from a disadvantaged group (aOR 3.84; [95% CI, 3.24-4.52]). Women who had companions during labor had fewer unnecessary cesarean births than those who had no companions (5.2% vs 6.8%, P < .001).

    CONCLUSIONS: In Nepal, sociodemographic factors affect women's likelihood of having a companion during labor. As companionship during labor is associated with improved quality of care, health facilities should encourage women's access to birth companions.

  • 4.
    KC, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Health Section, UNICEF, UN House, Lalitpur, Nepal.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Institute for Global Health, University College London, London, UK.
    Chaulagain, Dipak
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Lifeline Nepal, Kathmandu, Nepal.
    Brunell, Olivia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Gurung, Abhishek
    Lifeline Nepal, Kathmandu, Nepal.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Wrammert, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Grönqvist, Erik
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Economics.
    Edin, Per-Anders
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Economics.
    Le Grange, Claire
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Lamichhane, Bikash
    Department of Health Services, Ministry of Health, Nepal.
    Shrestha, Parashuram
    Department of Health Services, Ministry of Health, Nepal.
    Pokharel, Amrit
    Department of Health Services, Ministry of Health, Nepal.
    Pun, Asha
    Health Section, UNICEF, UN House, Lalitpur, Nepal.
    Singh, Chahana
    Health Section, UNICEF, UN House, Lalitpur, Nepal .
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial2017In: BMJ global health, Vol. 2, no 3, article id e000497Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Nepal Perinatal Quality Improvement Project (NePeriQIP) intends to scale up a quality improvement (QI) intervention for perinatal care according to WHO/National guidelines in hospitals of Nepal using the existing health system structures. The intervention builds on previous research on the implementation of Helping Babies Breathe-quality improvement cycle in a tertiary healthcare setting in Nepal. The objective of this study is to evaluate the effect of this scaled-up intervention on perinatal health outcomes.

    METHODS/DESIGN: Cluster-randomised controlled trial using a stepped wedged design with 3 months delay between wedges will be conducted in 12 public hospitals with a total annual delivery rate of 60 000. Each wedge will consist of 3 hospitals. Impact will be evaluated on intrapartum-related mortality (primary outcome), overall neonatal mortality and morbidity and health worker's performance on neonatal care (secondary outcomes). A process evaluation and a cost-effectiveness analysis will be performed to understand the functionality of the intervention and to further guide health system investments will also be performed.

    DISCUSSION: In contexts where resources are limited, there is a need to find scalable and sustainable implementation strategies for improved care delivery. The proposed study will add to the scarce evidence base on how to scale up interventions within existing health systems. If successful, the NePeriQIP model can provide a replicable solution in similar settings where support and investment from the health system is poor, and national governments have made a global pledge to reduce perinatal mortality.

    TRIAL REGISTRATION NUMBER: ISRCTN30829654.

  • 5.
    KC, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Berkelhamer, Sara
    Gurung, Rejina
    Hong, Zhou
    Wang, Haijun
    Sunny, Avinash K
    Bhattarai, Pratiksha
    Poudel, Pragya G
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    The burden of and factors associated with misclassification of intrapartum stillbirth: Evidence from a large scale multicentric observational study.2019In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Global estimates suggest 2.6 million stillbirths and 2.5 million neonatal deaths occur annually worldwide. The majority of these deaths occur in low resource settings where analysis of health metrics and outcomes measurements may be challenging. We examined the misclassification of documented intrapartum stillbirth and factors associated with misclassification.

    MATERIAL AND METHODS: A prospective observational study was performed in 12 public hospitals in Nepal. Data were extracted from the medical records of all births that occurred during the 6-month period of the study. For the study purpose, we classified birth outcome based on the presence of fetal heart sound (FHS) at admission and use of neonatal resuscitation. The health worker-documented intrapartum stillbirths were considered potentially misclassified when there were FHS present at admission and no resuscitation initiated after birth. The association between potentially misclassified intrapartum stillbirth and complications during labor, birthweight and gestational age was assessed using Pearson's chi-square test, bivariate and multivariate logistic regression.

    RESULTS: A total of 39 562 mother-infant dyads were enrolled in the study, all of whom had FHS at admission. Among the 391 intrapartum stillbirths recorded during the study, 180 (46.0%) of them had FHS at admission with no resuscitation initiated after birth and were considered potentially misclassified intrapartum stillbirths. Among these potentially misclassified intrapartum stillbirths, 170 (43.5%) had FHS present 15 minutes before birth and 10 had no FHS 15 minutes before birth Among the potentially misclassified intrapartum stillbirths, 23.3% had complications during labor, 93.3% had birthweight less than 2500 g and 90.0% were born preterm. The risk of intrapartum misclassification was nearly four times higher among low birthweight babies (adjusted odds ratio [aOR] 3.5, 95% confidence interval [CI] 1.8 to 7.0, P < 0.001) and five times higher among preterm babies (aOR 5.3, 95% CI 3.0 to 9.3, P < 0.001).

    CONCLUSIONS: We estimate that 46% of intrapartum stillbirths were potentially misclassified intrapartum stillbirths. Improving quality of both FHS monitoring and neonatal resuscitation as well as measurement of the care will reduce the risk of potentially misclassified intrapartum stillbirth and consequently intrapartum stillbirth.

  • 6.
    KC, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Basnet, Omkar
    Golden Community, Jawgal, Lalitpur, Nepal.
    Gurung, Abhishek
    Golden Community, Jawgal, Lalitpur, Nepal.
    Pyakuryal, Sushil Nath
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Jha, Bijay Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. UCL, UCL Inst Global Hlth IGH, London, England.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Paudel, Prajwal
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Karki, Sushil
    Life Line Nepal, Kathmandu, Nepal.
    Gajurel, Sunil
    Kamana Hlth Nepal, Kathmandu, Nepal.
    Brunell, Olivia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Wrammert, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Målqvist, Mats
    Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal: A stepped-wedge cluster randomized controlled trial2019In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 16, no 9, article id e1002900Article in journal (Refereed)
    Abstract [en]

    Background Improving quality of intrapartum care will reduce intrapartum stillbirth and neonatal mortality, especially in resource-poor settings. Basic neonatal resuscitation can reduce intrapartum stillbirth and early neonatal mortality, if delivered in a high-quality health system, but there is a dearth of evidence on how to scale up such evidence-based interventions. We evaluated the scaling up of a quality improvement (QI) package for neonatal resuscitation on intrapartum-related mortality (intrapartum stillbirth and first day mortality) at hospitals in Nepal. Methods and findings We conducted a stepped-wedge cluster randomized controlled trial in 12 hospitals over a period of 18 months from April 14, 2017, to October 17, 2018. The hospitals were assigned to one of four wedges through random allocation. The QI package was implemented in a stepped-wedge manner with a delay of three months for each step. The QI package included improving hospital leadership on intrapartum care, building health workers' competency on neonatal resuscitation, and continuous facilitated QI processes in clinical units. An independent data collection system was set up at each hospital to gather data on mortality through patient case note review and demographic characteristics of women using semi-structured exit interviews. The generalized linear mixed model (GLMM) and multivariate logistic regression were used for analyses. During this study period, a total of 89,014 women-infant pairs were enrolled. The mean age of the mother in the study period was 24.0 +/- 4.3 years, with 54.9% from disadvantaged ethnic groups and 4.0% of them illiterate. Of the total birth cohort, 54.4% were boys, 16.7% had gestational age less than 37 weeks, and 17.1% had birth weight less than 2,500 grams. The incidence of intrapartum-related mortality was 11.0 per 1,000 births during the control period and 8.0 per 1,000 births during the intervention period (adjusted odds ratio [aOR], 0.79; 95% CI, 0.69-0.92; p = 0.002; intra-cluster correlation coefficient [ICC], 0.0286). The incidence of early neonatal mortality was 12.7 per 1,000 live births during the control period and 10.1 per 1,000 live births during the intervention period (aOR, 0.89; 95% CI, 0.78-1.02; p = 0.09; ICC, 0.1538). The use of bag-and-mask ventilation for babies with low Apgar score (<7 at 1 minute) increased from 3.2% in the control period to 4.0% in the intervention period (aOR, 1.52; 95% CI, 1.32-1.77, p = 0.003). There were two major limitations to the study; although a large sample of women-infant pairs were enrolled in the study, the clustering reduced the power of the study. Secondly, the study was not sufficiently powered to detect reduction in early neonatal mortality with the number of clusters provided. Conclusion These results suggest scaled-up implementation of a QI package for neonatal resuscitation can reduce intrapartum-related mortality and improve clinical care. The QI intervention package is likely to be effective in similar settings. More implementation research is required to assess the sustainability of QI interventions and quality of care.

  • 7.
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    'What about the Mother?': Rising Caesarean Section Rates and their Association with Maternal Near-Miss Morbidity and Death in a Low-Resource Setting2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    In recent decades, there has been a seemingly inexhaustible rise in the use of caesarean section (CS) worldwide. The overall aim with this thesis is to explore the effects of and reasons for an increase in the CS rate at a university hospital in Dar es Salaam, Tanzania.

    In Study I, we analysed time trends in CS rates and maternal and perinatal outcomes between 2000 and 2011 among different obstetric groups. In Study II, we documented the occurrence and panorama of maternal ‘near-miss’ morbidity and death, and analysed their association with CS complications. We also strived to determine if women with previous CS scars had an increased risk of maternal near-miss, death, or adverse perinatal outcomes in subsequent pregnancies. Studies III and IV explored women’s and caregivers’ in-depth perspectives on CS and caregivers’ rationales for their hospital’s high CS rate.

    During the study period, the CS rate increased from 19% to 49%. The rise was accompanied by an increased maternal mortality ratio (odds ratio [OR] 1.5, 95% Confidence Interval [CI] 1.2–1.8) and improved perinatal outcomes. CS complications accounted for 7.9% (95% CI 5.6–11) of the maternal near-miss events and 13% (95% CI 6.4–23) of the maternal deaths. Multipara with previous CS scars had no increased risk of maternal near-miss or death compared with multipara with previous vaginal deliveries, and a lower risk of adverse perinatal outcomes (adjusted OR 0.51, 95% CI 0.33–0.80). Both women and caregivers stated they preferred vaginal birth, but caregivers also had a favourable attitude towards CS. Both groups justified maternal risks with CS by the need to ‘secure’ a healthy baby. Caregivers stated that they sometimes performed CSs on doubtful indications, partly due to dysfunctional team-work and a fear of being blamed by colleagues. 

    This thesis raises a concern that maternal health, interests, and voices are overlooked through the CS decision for the benefit of perinatal outcomes and caregivers’ liability. An overuse of CS should be seen as a sign of substandard care and preventing such overuse needs to be among the key actions when formulating new targets for the post-2015 era.

    List of papers
    1. Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania
    Open this publication in new window or tab >>Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania
    Show others...
    2013 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, p. 107-Article in journal (Refereed) Published
    Abstract [en]

    Background: Rising caesarean section (CS) rates have been observed worldwide in recent decades. This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country. Methods: We conducted a hospital-based panel study at Muhimbili National Hospital, Dar es Salaam, Tanzania. All deliveries between 2000 and 2011 with gestational age >= 28 weeks were included in the study. The 12 years were divided into four periods: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. Main outcome measures included CS rate, relative size of obstetric groups, contribution to overall CS rate, perinatal mortality ratio, neonatal distress, and maternal mortality ratio. Time trends were analysed within the ten Robson groups, based on maternal and obstetric characteristics. We applied the chi(2) test for trend to determine whether changes were statistically significant. Odds ratios of CS were evaluated using multivariate logistic regression, accounting for maternal age, referral status, and private healthcare insurance. Results: We included 137,094 deliveries. The total CS rate rose from 19% to 49%, involving nine out of ten groups. Multipara without previous CS with single, cephalic pregnancies in spontaneous labour had a CS rate of 33% in 2009 to 2011. Adjusted analysis explained some of the increase. Perinatal mortality and neonatal distress decreased in multiple pregnancies (p < 0.001 and p = 0.003) and nullipara with breech pregnancies (p < 0.001 and p = 0.024). Although not statistically significant, there was an increase in perinatal mortality (p = 0.381) and neonatal distress (p = 0.171) among multipara with single cephalic pregnancies in spontaneous labour. The maternal mortality ratio increased from 463/100, 000 live births in 2000 to 2002 to 650/100, 000 live births in 2009 to 2011 (p = 0.031). Conclusion: The high CS rate among low-risk groups suggests that many CSs might have been performed on questionable indications. Such a trend may result in even higher CS rates in the future. While CS can improve perinatal outcomes, it does not necessarily do so if performed routinely in low-risk groups.

    Keywords
    Caesarean section, Robson classification, Low-income countries
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-202372 (URN)10.1186/1471-2393-13-107 (DOI)000319062400001 ()
    Available from: 2013-06-24 Created: 2013-06-24 Last updated: 2017-12-06Bibliographically approved
    2. Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania
    Open this publication in new window or tab >>Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania
    Show others...
    2014 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, no 1, p. 244-Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND:

    The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications.

    METHODS:

    We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital in Dar es Salaam, Tanzania. Cases were assessed individually to determine their association with CS. Main outcome measures included MNM ratio; maternal mortality ratio; proportion of MNM and death associated with CS complications; and the risk for such outcomes per 1,000 operations. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was calculated.

    RESULTS:

    We identified 467 MNM events and 77 maternal deaths. The MNM ratio was 36 per 1,000 live births (95% CI 33-39) and the maternal mortality ratio was 587 per 100,000 live births (95% CI 460-730). Major causes were eclampsia and postpartum haemorrhage, but we also detected nine MNM events and five deaths from iatrogenic complications. CS complications accounted for 7.9% (95% CI 5.6-11) of the MNM events and 13% (95% CI 6.4-23) of the maternal deaths. The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital (22/1,000 operations, 95% CI 12-37) compared to the university hospital (7.0/1,000 operations, 95% CI 3.8-12) (risk ratio 3.2, 95% CI 1.5-6.6).

    CONCLUSIONS:

    The occurrence of MNM and death at the two hospitals was high, and many cases were associated with CS complications. The maternal risks of CS in low-resource settings must not be overlooked, and measures should be taken to avoid unnecessary CSs. More comprehensive training of staff, improved postoperative surveillance, and a more even distribution of resources within the health care system might reduce the risks of CS.

    National Category
    Public Health, Global Health, Social Medicine and Epidemiology
    Identifiers
    urn:nbn:se:uu:diva-229946 (URN)10.1186/1471-2393-14-244 (DOI)000340799000001 ()25056517 (PubMedID)
    Available from: 2014-08-18 Created: 2014-08-18 Last updated: 2017-12-05Bibliographically approved
    3. "What about the mother?": Women's and caregivers' perspectives on caesarean birth in a low-resource setting with rising caesarean section rates
    Open this publication in new window or tab >>"What about the mother?": Women's and caregivers' perspectives on caesarean birth in a low-resource setting with rising caesarean section rates
    Show others...
    2015 (English)In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 31, no 7, p. 713-720Article in journal (Refereed) Published
    Abstract [en]

    Objective: in light of the rising caesarean section rates in many developing countries, we sought to explore women's and caregivers' experiences, perceptions, attitudes, and beliefs in relation to caesarean section. Design: qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis. Setting: a public university hospital in Dar es Salaam, Tanzania. Participants: we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each Women had undergone a caesarean section within two months preceding the interview and were interviewed in their homes. Caregivers were consultants, specialists, residents, and midwives. Findings: both women and caregivers preferred vaginal birth, but caregivers also had a favourable attitude towards caesarean section. While caregivers emphasised their efforts to counsel women on caesarean section, women had often reacted with fear and shock to the caesarean section decision and perceived that there was a lack of indications. Although caesarean section was perceived as involving higher maternal risks than vaginal birth, both women and caregivers justified these risks by the need to 'secure' a healthy baby. Religious beliefs and community members seemed to influence women's caesarean section attitudes, which often made caregivers frustrated as it diminished their role as decision makers Undergoing caesarean section had negative socio-economic consequences for women and their families; however, caregivers seldom took these factors into account when making decisions. Key conclusions and implications for practice: we raise a concern that women and caregivers might overlook maternal risks with caesarean section for the benefit of the baby, a shift in focus that can have serious consequences on women's health in low-resource settings. Caregivers need to reflect on how they counsel women on caesarean section, as many women perceived a lack of indication for their operations. Supportive attendance by a relative during birth and more comprehensive antenatal care counselling about caesarean section indications and complications might enhance women's autonomy and birth preparedness.

    National Category
    Obstetrics, Gynecology and Reproductive Medicine
    Identifiers
    urn:nbn:se:uu:diva-238473 (URN)10.1016/j.midw.2015.03.008 (DOI)000356237500010 ()25886967 (PubMedID)
    Funder
    Swedish Research Council
    Available from: 2014-12-15 Created: 2014-12-12 Last updated: 2017-12-05Bibliographically approved
    4. Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting
    Open this publication in new window or tab >>Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting
    Show others...
    2015 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 143, p. 232-240Article in journal (Refereed) Published
    Abstract [en]

    In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5-6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings in the discussion of how transparency and auditing can induce behavioral change and have unintended effects. Caregivers had divergent opinions on whether the hospital's CS rate was a problem or not, but most thought that there was an overuse of CS. All caregivers rationalized the high CS rate by referring to circumstances outside their control. In private practice, some stated they were affected by the economic compensation for CS, while others argued that unnecessary CSs were due to maternal demand. Residents often missed support from their senior colleagues when making decisions, and felt that midwives pushed them to perform CSs. Many caregivers stated that their fear of blame from colleagues and management in case of poor outcomes made them advocate for, or perform, CSs on doubtful indications. In order to lower CS rates, caregivers must acknowledge their roles as decision-makers, and strive to minimize unnecessary CSs. Although auditing and transparency are important to improve patient safety, they must be used with sensitivity regarding any unintended or counterproductive effects they might have.

    Keywords
    Tanzania; Caesarean section; Low-resource setting; Attitudes; Caregivers; Transparency
    National Category
    Obstetrics, Gynecology and Reproductive Medicine
    Identifiers
    urn:nbn:se:uu:diva-238477 (URN)10.1016/j.socscimed.2015.09.003 (DOI)000364245600027 ()26364010 (PubMedID)
    Funder
    Swedish Research Council
    Available from: 2014-12-15 Created: 2014-12-12 Last updated: 2017-12-05Bibliographically approved
  • 8.
    Litorp, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Kidanto, Hussein L.
    Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania.
    Nystrom, Lennarth
    Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania2013In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, p. 107-Article in journal (Refereed)
    Abstract [en]

    Background: Rising caesarean section (CS) rates have been observed worldwide in recent decades. This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country. Methods: We conducted a hospital-based panel study at Muhimbili National Hospital, Dar es Salaam, Tanzania. All deliveries between 2000 and 2011 with gestational age >= 28 weeks were included in the study. The 12 years were divided into four periods: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. Main outcome measures included CS rate, relative size of obstetric groups, contribution to overall CS rate, perinatal mortality ratio, neonatal distress, and maternal mortality ratio. Time trends were analysed within the ten Robson groups, based on maternal and obstetric characteristics. We applied the chi(2) test for trend to determine whether changes were statistically significant. Odds ratios of CS were evaluated using multivariate logistic regression, accounting for maternal age, referral status, and private healthcare insurance. Results: We included 137,094 deliveries. The total CS rate rose from 19% to 49%, involving nine out of ten groups. Multipara without previous CS with single, cephalic pregnancies in spontaneous labour had a CS rate of 33% in 2009 to 2011. Adjusted analysis explained some of the increase. Perinatal mortality and neonatal distress decreased in multiple pregnancies (p < 0.001 and p = 0.003) and nullipara with breech pregnancies (p < 0.001 and p = 0.024). Although not statistically significant, there was an increase in perinatal mortality (p = 0.381) and neonatal distress (p = 0.171) among multipara with single cephalic pregnancies in spontaneous labour. The maternal mortality ratio increased from 463/100, 000 live births in 2000 to 2002 to 650/100, 000 live births in 2009 to 2011 (p = 0.031). Conclusion: The high CS rate among low-risk groups suggests that many CSs might have been performed on questionable indications. Such a trend may result in even higher CS rates in the future. While CS can improve perinatal outcomes, it does not necessarily do so if performed routinely in low-risk groups.

  • 9.
    Litorp, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kidanto, Hussein L
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Rööst, Mattias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Abeid, Muzdalifat
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nyström, Lennarth
    Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, no 1, p. 244-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications.

    METHODS:

    We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital in Dar es Salaam, Tanzania. Cases were assessed individually to determine their association with CS. Main outcome measures included MNM ratio; maternal mortality ratio; proportion of MNM and death associated with CS complications; and the risk for such outcomes per 1,000 operations. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was calculated.

    RESULTS:

    We identified 467 MNM events and 77 maternal deaths. The MNM ratio was 36 per 1,000 live births (95% CI 33-39) and the maternal mortality ratio was 587 per 100,000 live births (95% CI 460-730). Major causes were eclampsia and postpartum haemorrhage, but we also detected nine MNM events and five deaths from iatrogenic complications. CS complications accounted for 7.9% (95% CI 5.6-11) of the MNM events and 13% (95% CI 6.4-23) of the maternal deaths. The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital (22/1,000 operations, 95% CI 12-37) compared to the university hospital (7.0/1,000 operations, 95% CI 3.8-12) (risk ratio 3.2, 95% CI 1.5-6.6).

    CONCLUSIONS:

    The occurrence of MNM and death at the two hospitals was high, and many cases were associated with CS complications. The maternal risks of CS in low-resource settings must not be overlooked, and measures should be taken to avoid unnecessary CSs. More comprehensive training of staff, improved postoperative surveillance, and a more even distribution of resources within the health care system might reduce the risks of CS.

  • 10.
    Litorp, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mgaya, Andrew
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Johnsdotter, Sara
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    "What about the mother?": Women's and caregivers' perspectives on caesarean birth in a low-resource setting with rising caesarean section rates2015In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 31, no 7, p. 713-720Article in journal (Refereed)
    Abstract [en]

    Objective: in light of the rising caesarean section rates in many developing countries, we sought to explore women's and caregivers' experiences, perceptions, attitudes, and beliefs in relation to caesarean section. Design: qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis. Setting: a public university hospital in Dar es Salaam, Tanzania. Participants: we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each Women had undergone a caesarean section within two months preceding the interview and were interviewed in their homes. Caregivers were consultants, specialists, residents, and midwives. Findings: both women and caregivers preferred vaginal birth, but caregivers also had a favourable attitude towards caesarean section. While caregivers emphasised their efforts to counsel women on caesarean section, women had often reacted with fear and shock to the caesarean section decision and perceived that there was a lack of indications. Although caesarean section was perceived as involving higher maternal risks than vaginal birth, both women and caregivers justified these risks by the need to 'secure' a healthy baby. Religious beliefs and community members seemed to influence women's caesarean section attitudes, which often made caregivers frustrated as it diminished their role as decision makers Undergoing caesarean section had negative socio-economic consequences for women and their families; however, caregivers seldom took these factors into account when making decisions. Key conclusions and implications for practice: we raise a concern that women and caregivers might overlook maternal risks with caesarean section for the benefit of the baby, a shift in focus that can have serious consequences on women's health in low-resource settings. Caregivers need to reflect on how they counsel women on caesarean section, as many women perceived a lack of indication for their operations. Supportive attendance by a relative during birth and more comprehensive antenatal care counselling about caesarean section indications and complications might enhance women's autonomy and birth preparedness.

  • 11.
    Litorp, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mgaya, Andrew
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mbekenga, Columba K.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Johnsdotter, Sara
    Malmo Univ, Fac Hlth & Soc, S-20506 Malmo, Sweden.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting2015In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 143, p. 232-240Article in journal (Refereed)
    Abstract [en]

    In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5-6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings in the discussion of how transparency and auditing can induce behavioral change and have unintended effects. Caregivers had divergent opinions on whether the hospital's CS rate was a problem or not, but most thought that there was an overuse of CS. All caregivers rationalized the high CS rate by referring to circumstances outside their control. In private practice, some stated they were affected by the economic compensation for CS, while others argued that unnecessary CSs were due to maternal demand. Residents often missed support from their senior colleagues when making decisions, and felt that midwives pushed them to perform CSs. Many caregivers stated that their fear of blame from colleagues and management in case of poor outcomes made them advocate for, or perform, CSs on doubtful indications. In order to lower CS rates, caregivers must acknowledge their roles as decision-makers, and strive to minimize unnecessary CSs. Although auditing and transparency are important to improve patient safety, they must be used with sensitivity regarding any unintended or counterproductive effects they might have.

  • 12.
    Litorp, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Rööst, Mattias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania..
    Nyström, Lennarth
    Umea Univ, Dept Publ Hlth & Clin Med, Epidemiol & Global Hlth, Umea, Sweden..
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    The effects of previous cesarean deliveries on severe maternal and adverse perinatal outcomes at a university hospital in Tanzania2016In: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 133, no 2, p. 183-187Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate if multiparous individuals who had undergone a previous cesarean delivery experienced an increased risk of severe maternal outcomes or adverse perinatal outcomes compared with multiparous individuals who had undergone previous vaginal deliveries. Methods: An analytical cross-sectional study at a university hospital in Dar es Salaam, Tanzania, enrolled multiparous participants of at least 28 weeks of pregnancy between February 1 and June 30, 2012. Data were collected from patients' medical records and the hospital's obstetric database. Odds ratios (OR) and 95% confidence intervals (Cl) were calculated to compare outcomes among patients who had or had not undergone previous cesarean deliveries. Results: A total of 2478 patients were enrolled. A previous cesarean delivery resulted in no increase in the risk of severe maternal outcomes (OR0.86, 95% CI 0.58-1.26; P = 0.46), and decreased risk of stillbirth (OR 0.42, 95% CI 0.29-0.62, P < 0.001), and intrapartum stillbirth and neonatal distress (OR 0.58, 95% CI 038-0.87, P = 0.007). Conclusion: Previous cesarean delivery was not a risk factor for severe maternal outcomes or adverse perinatal outcomes. The present study was conducted at a referral institution, where individuals with previous cesarean deliveries may constitute a healthy group. Additionally, there could be differences between the study groups in terms of healthcare-seeking behavior, referral mechanisms, intrapartum monitoring, and clinical decision making.

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