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印度基于辅导的WHO安全分娩清单项目的结局
Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India


Katherine E.A. Semrau ... 妇产科和儿科 • 2017.12.14

摘要


背景

尽管过去20年,资源匮乏地区妊娠女性在医疗机构分娩的普及程度方面有了极大提高,但是护理质量仍存在差距,死亡率仍然很高。世界卫生组织(WHO)的《安全分娩清单》(Safe Childbirth Checklist)则是一项改善分娩质量的有效工具,它可提高对护理操作的总体依从性,而研究已发现这些实践与分娩结局的改善具有相关性。


方法

我们在印度北方邦(Uttar Pradesh)24个县的60对(120家)医疗机构内进行了一项配对设计的整群随机对照试验,测试了“优生”计划对于包括分娩后7日内围生期死亡率、产妇死亡率或产妇重度并发症发生率等在内的复合结局的影响。“优生”计划是一项对《安全分娩清单》为期8个月的指导式实施。结局的评估在分娩后8~42日进行。对分群和配对进行校正后我们比较了干预组和对照组的结局。我们还在启动干预后2个月和12个月时,比较了15组配对的医疗机构内助产人员对18项关键性分娩实践操作规范的依从性。


结果

在161,107例符合条件的女性中,我们纳入了157,689例(97.9%),确定了其中157,145例(99.7%)母亲-新生儿二元组的7日结局。在我们进行观察的4,888例分娩中,干预组内助产人员的平均操作依从性显著高于对照组(2个月时为72.8% vs. 41.7%,P<0.001;12个月时为61.7% vs. 43.9%,P<0.001)。然而试验组间的复合主要结局无显著差异(干预组15.1%,对照组15.3%;相对风险,0.99;95%置信区间,0.83~1.18;P=0.90);产妇或围生期不良次要结局也无显著差异。


结论

实施了指导式WHO《安全分娩清单》计划的医疗机构内,助产人员对于关键性分娩操作的依从性,高于未实施《安全分娩清单》计划的机构,但是两组间的产妇和围生期死亡率,以及产妇发病率均无显著差异(由比尔及梅琳达·盖茨基金会资助;临床试验注册号NCT02148952)。





作者信息

Katherine E.A. Semrau, Ph.D., M.P.H., Lisa R. Hirschhorn, M.D., M.P.H., Megan Marx Delaney, R.N., M.S.N., M.P.H., Vinay P. Singh, P.G.D.G.B.M., B.Tech., Rajiv Saurastri, M.A., Narender Sharma, Ph.D., M.B.A., Danielle E. Tuller, M.H.S., Rebecca Firestone, Sc.D., M.P.H., Stuart Lipsitz, Sc.D., Neelam Dhingra-Kumar, M.D., M.B., B.S., Bhalachandra S. Kodkany, M.D., D.G.O., M.B., B.S., Vishwajeet Kumar, M.D., M.P.H., and Atul A. Gawande, M.D., M.P.H., for the BetterBirth Trial Group*
From Ariadne Labs–Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women’s Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) — all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) — all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.). Address reprint requests to Dr. Semrau at Ariadne Labs, 401 Park Dr., 3rd Flr. E., Boston, MA 02215, or at ksemrau@ariadnelabs.org. *A complete list of investigators in the BetterBirth Trial Group is provided in the Supplementary Appendix, available with the full text of this article at NEJM.org.

 

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