Critical signs and symptoms for self-assessment in the immediate postnatal period: an international Systematic Scoping Review and Delphi consensus study

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Most maternal deaths occur within the first 24 hours following birth, highlighting the importance of immediate postnatal care (iPNC). Self-care strategies are increasingly being employed to promote women-centred, continuous care provision. Despite international calls for development of strategies promoting self-care, none have been developed for self-monitoring in the immediate postnatal period. Fundamental to the development of a self-monitoring strategy, is an understanding of which signs and symptoms are predictive of maternal morbidity and mortality and can be easily assessed by mothers and birth companions, in health facilities, without the need for equipment. The objective of this study was to develop and achieve international consensus on the key signs and symptoms. Methods A multi-step approach involving a systematic scoping review, two- round Delphi Survey, and expert consensus was employed to identify key signs and symptoms that can be self- assessed and predict morbidity and mortality in the immediate postnatal period. Results A comprehensive list of 351 key signs and symptoms was identified from 44 clinical practice guidelines. Subsequently, 134 signs and symptoms were reviewed by Delphi respondents and international expert consensus was achieved for 19 key signs and symptoms across seven condition categories. The signs that were considered both important and able to be self-assessed by mothers and birth companions in the first 24 hours following birth included change in consciousness, seizure, severe headache, persistent visual impairment, urinary incontinence, chest pain, shortness of breath, severe pallor, fast heartbeat, rejection of baby, suicidal/infanticidal, fever, heavy blood loss, soft flabby uterus, unable to urinate easily, foul smelling discharge, rigors, syncope/dizziness, abnormal coloured urine. Conclusion This study identified key signs and symptoms which can be easily assessed by mothers and birth companions in the immediate postnatal period to identify those most at risk of morbidity and mortality. Further work is needed to validate this screening tool, and adapt it for other regions and countries. Figures Figure 1 Background According to the latest United Nations (UN) estimates, a woman dies from complications of pregnancy and childbirth every two minutes. 1 Most maternal mortality occurs within the first 24 hours and a focus on immediate postnatal care (iPNC) is therefore important. 2 , 3 Despite its lifesaving value, postnatal care is critically neglected. One in five mothers and babies do not have access to life-saving postnatal care interventions. 4 Furthermore, the COVID-19 pandemic resulted in increasing fragmentation and disruption of essential reproductive health services including postnatal care. There is an urgent need for new and innovative strategies for postnatal care to ensure the accelerated reduction in global maternal deaths needed to achieve the Sustainable Development Goal Target 3.1 by 2030. 1 Recent global crises have highlighted self-care strategies as effective mechanisms to ensure continued provision of services, promote women centred care and achieve universal health coverage. As such the World Health Organization (WHO) has made a call for strategies and interventions that promote self-care. 5 Yet within the existing list of self-care interventions, there is a lack of strategies for self-monitoring in the immediate postnatal period by mothers, supported by their birth companions, in health facilities. 6 Developing self-monitoring strategies requires an understanding of the key signs and symptoms and whether these could be easily assessed by mothers and birth companions in the immediate postnatal period. To date, there is no existing research nor consensus on this. The objective of this study was to achieve international consensus on a list of key immediate postnatal signs and symptoms that are predictive of maternal morbidity and which mothers, or their birth companions could self-assess in health facilities during the immediate postnatal period, without the need for additional equipment. Methods A multi-step approach was utilised for this process including systematic scoping review, expert review and Delphi survey. (Table 1 ) Table 1 Process for establishing content of the Immediate Postnatal Women’s Assessment (ImPoWA) tool Step Aims Participants Methods 1 Systematic scoping literature review to generate a comprehensive list of signs and symptoms that clinical practice guidelines suggest should be assessed in the immediate postnatal period N/A Systematic scoping literature review 2 Review of systematic scoping review findings to agree on the content validity of key signs and symptoms for inclusion in Delphi Survey Expert Committee Group Discussion 3 Rating of the importance of signs and symptoms, and suggestion of any new additions Delphi respondents (identified through snowball sampling) Delphi Survey 4 Repeat of step 3 with the refined list Invitations to same Delphi respondents as in step 3 above Delphi Survey 5 Review of unresolved signs and symptoms, and achieving final consensus on tool content. Expert Committee Group Discussion Step 1: Systematic Scoping Review A systematic scoping review was undertaken to identify a comprehensive list of signs and symptoms that international clinical practice guidelines (CPG’s) suggest should be assessed within the immediate postnatal period. The review question was broad and as such PROSPERO advised the authors to conduct a scoping review. That said, the authors were committed to conduct the review rigorously and adopt a systematic approach. As such, the review was also conducted in accordance with PRISMA guidelines. 7 The most recent versions of CPGs, available in English and published between January 2010 and June 2020, were included. Guidelines were excluded that were not specific to postnatal mothers or did not specify signs or symptoms to be assessed during the postnatal period. Primary and secondary research studies, conference abstracts, locally created CPGs, or those focusing on COVID-19 were excluded. A three-step search strategy was used (Appendix 1). Firstly, a comprehensive search of 15 published and three unpublished databases electronic databases was conducted. Secondly, a search of maternal health professional organisations and societies websites was conducted. Thirdly, the reference lists of selected guidelines were reviewed to identify additional CPGs. Title and abstract screening was conducted by one reviewer (NB). Full text screening was conducted by two reviewers (TD, NB), with a third reviewer (ADW) available to discuss any disagreements. Data was extracted by TD and NB in duplicate to a pre-created data extraction form. Signs and symptoms were transcribed literally before being organised into categories according to the clinical condition they related to, based on clinical opinion. Any duplicated signs or symptoms were removed at this stage. The quality of included CPGs was assessed by two reviewers (TD, NB) using the AGREE II tool with a third reviewer (ADW) consulted to discuss discrepancies. 8 In line with previous literature, a score of > 60% for each domain was considered sufficient. 8 – 10 Finally, two reviewers (TD, NB) provided an overall assessment of each guideline, using the following parameters: ‘Recommended’ was assigned if most domains (four or more) scored above 60%. ‘Recommended with modifications’ was assigned if most domains (four or more) scored between 30–60%. ‘Not recommended’ was assigned to any guidelines where most (four of more) of the domains scored below 30%. Guidelines listed as ‘recommended’ or ‘recommended with modifications’ were selected for inclusion. Those guidelines listed as not recommended were excluded. Step 2: Expert Committee A committee of nine experts was purposively selected from members of international and national groups focused on optimising postnatal care provision and uptake (Appendix 2). The Expert Committee reviewed the systematic scoping review findings to assess content validity. Discussions focused on three questions: How likely are these signs and symptoms to occur in the first 24 hours following birth? How essential or likely is the sign or symptom to predict maternal morbidity and morbidity within 24 hours of birth? Can the sign or symptom be easily assessed by a mother or her birth companion without extensive training? The Expert Committee were invited to suggest any additional signs and symptoms they deemed pertinent for inclusion. Step 3 and 4: Delphi Survey A two-round anonymised electronic Delphi Survey was designed on Joint Information Systems Committee (JISC) software. 11 E-mail invitations, including a link to the Delphi Survey, were sent to relevant contacts of the research team to participate in the study. Invitees were encouraged to share the survey in their network resulting in snowball recruitment. The survey was also advertised through social media to gain a global response. Newly identified participants were sent personal e-mail invitations to participate in the study including a link to the survey. There are no clear guidelines on sample size calculations required for a Delphi Survey. 12 , 13 Previous models have suggested that a minimum of five in each area of expertise would be sufficient to be provide content validity and varied input to produce meaningful and generalisable results. 12 , 13 Initial stakeholder mapping identified four key stakeholder groups to be included (Clinicians, Academics/Researchers, Public Health officers and programmers, Women’s Representatives). The researchers aimed towards a minimum sample size of 50 participants to account for potential attrition in Round 2 and likelihood of respondents crossing stakeholder groups. During the Delphi Survey, participants were asked to rate the importance and possibility for mothers and birth companions to assess each of the signs and symptoms. Participants were asked to rate between 1 and 7 on a Likert scale with 1–2 being ‘not important’, 3–5 being ‘important but not critical’ and 6–7 being ‘critically important’. Participants had the option to select “unable to comment”. In round 1, a free-text option enabled participants to suggest additional signs and symptoms that were not already listed. Consensus for the Delphi Survey was defined a priori based on the limits used to develop the core outcome sets. 14 In this study, for an item to have achieved full consensus and be termed ‘critically important’, at least 75% of participants needed to score the item as ‘critically important’ with < 15% of participants scoring the item as ‘not important’. Items that did not achieve consensus and were scored ‘not important’ required at least 75% of participants to score it as such and < 15% to score the item as ‘critically important’. Any items not meeting either category would have achieved some consensus and be termed “somewhat important”. A sensitivity analysis was conducted for signs and symptoms graded as “somewhat important”. Signs and symptoms with similar phrasings were arranged under a specific sign/symptom category irrespective of condition. The highest score each respondent attributed to any of the signs and symptoms within that category was recorded. Each sign and symptom was graded using the Likert scale, as above. First round of the Delphi Survey The first Delphi Survey was open for four weeks. Two reminder emails were sent to non-responders across the survey period. During the first round of the Delphi Survey, no signs or symptoms could be excluded. An additional 10 signs and symptoms were suggested by the respondents and added, resulting in a new questionnaire with 144 signs and symptoms for the second round of the Delphi Survey. Second round of the Delphi Survey Responders to the first Delphi survey were also invited to participate in the second round. No new participants were invited at this stage and non-responders from round 1 were not invited to participate in round 2. In Round 2, the revised questionnaire containing the 144 signs and symptoms was emailed directly to the Round 1 Delphi respondents. Within the survey, participants were provided with the results from round 1 (percentage of participants rating each sign or symptom as critically important), based on Delphi methodology. This enabled those receiving the survey to reflect on existing responses before completing round 2. 15 The Delphi Survey closed 4 weeks after the start of round 2 and weekly reminder emails were sent until closure of the questionnaire. Step 5: Consultation meeting The Expert Committee met to discuss the results of round 1 and 2 of the Delphi Survey. Prior to the meeting, the committee were provided with the collated results from both rounds of the survey. The committee members were asked to prioritise the list of key signs and symptoms deemed most critical (> 75% or above). Duplicates, those considered difficult for the mothers and birth companions to assess, and those occurring over 24 hours after birth were removed from the list. Next the list of signs and symptoms deemed ‘somewhat critical’ were reviewed. Duplicates, and those considered difficult for the mothers and birth companions to assess, were removed from the list. Finally, the committee reviewed all results to reach a final consensus on the key signs and symptoms that could be self-assessed by mothers, with the support of their birth companions. Ethics approval for this study was gained through University of Liverpool Ethical Review Committee (Ref: 9743). Results Step 1: Systematic scoping review A total of 20,734 articles relevant to iPNC were identified (Appendix 3) were screened. Forty-four CPGs were identified, which met eligibility criteria, and were included in the review (Appendix 4). Of these guidelines, 13 were intended for an international audience, 30 were specifically for high income countries and six were created for low- and middle-income country (LMIC) settings. Only 11 guidelines were specifically for the postnatal period. A total of 351 maternal signs and symptoms, across 12 condition categories pertaining to the immediate postnatal period, were identified. Step 2: Expert Committee The Expert Committee reviewed the initial list of 351 signs and symptoms for content validity. One duplicate was removed, and 232 signs and symptoms were excluded. One hundred and seven were deemed unlikely to occur within the first 24 hours of birth; 45 were not considered essential for predicting maternal morbidity and mortality; and 79 were considered unsuitable for assessment by a mother or her birth companion, without additional equipment. Alternative phrasing was proposed for six signs and symptoms that had previously been excluded and as such were re-added. An additional nine signs/symptoms were suggested. Discussions resulted in the creation of a list of 134 signs and symptoms, arranged in seven condition categories, to be reviewed during the first round of the Delphi Survey (Appendix 5). Steps 3 and 4: Delphi Survey One hundred and thirteen respondents, from 10 countries, completed round one of the Delphi Survey. Fifty-nine of these respondents, from nine countries, subsequently completed round two (52%) Most of the round two respondents (94%) were practising health care workers (Table 2 ). Most respondents had been working in clinical practice for at least 5 years. There were 51% of respondents from high-income-settings, 37% from lower-middle-income settings and 12% from low-income settings. Table 2 Demographics of Delphi respondents Round 1 (n = 113) Round 2 (n = 59) Number % Number % Role Clinicians 101 89 55 94 Academics/researchers 6 6 2 3 Public Health officers and programmers 5 4 2 3 Women’s representatives 1 1 - - Length of Duty > 10 years 61 54 31 53 5–10 years 26 23 16 27 2–4 years 15 13 6 10 1 year or less 11 9 6 10 Country UK 40 36 28 48 Nigeria 22 19 7 12 Uganda 16 14 7 12 Kenya 14 12 6 10 Nepal 11 9 4 7 Tanzania 2 2 2 3 USA 2 2 2 3 India 4 4 2 3 Ghana 1 1 1 2 Australia 1 1 - - Step 5: Expert Committee When reviewing the results of each round of the Delphi Survey, the Expert Committee highlighted the value of a broad list of signs and symptoms, not limited to specific conditions occurring in the postnatal period, given that many signs and symptoms span multiple conditions. Of the 144 signs and symptoms reviewed in round 2 of the Delphi survey, 35 (24%) were considered ‘critically important’; 109 (76%) ‘somewhat important’; and none were deemed unimportant or excluded (Fig. 1 ). ‘Critically important’ signs and symptoms Of the 35 most critically important signs, the Expert Committee excluded 23 of them. Thirteen were duplicates; 10 were deemed difficult for a mother and birth companion to assess without training and equipment or would occur after 24 hours following birth. Twelve were selected for inclusion in the list of key signs and symptoms. These included, “change in consciousness, seizure, severe headache, persistent visual impairment, urinary incontinence, chest pain, shortness of breath, severe pallor, fast heartbeat, rejection of baby, suicidal/infanticidal, fever”. ‘Somewhat important’ signs and symptoms For the 109 somewhat important signs and symptoms, a sensitivity analysis was conducted. Ten signs and symptoms categories contained at least one sign or symptom that was scored as “critically important” by more than 75% of respondents. These were dizziness, amount of blood loss, foul smelling discharge, hallucinations/delusions, inability to pass urine, depression, rigors, lethargy, coloured urine and soft flabby uterus. Fifty-four signs and symptoms were listed within the ten sign and symptoms categories and excluded as duplicates. Forty-five signs and symptoms were not housed within the ten important signs and symptoms categories and excluded as deemed not important. The Expert Committee advised renaming two of the signs and symptoms for clarity. Coloured urine was renamed “abnormally coloured urine”, and amount of blood loss was renamed “heavy blood loss”. Three signs and symptoms; “lethargy”, “hallucinations and delusions” and “depression” were excluded as the Expert Committee considered them to be difficult for a mother and birth companion to assess. A final list of 19 signs and symptoms that were important and possible to be assessed in the immediate postnatal period were selected as below: Change in consciousness Seizure Severe Headache Persistent visual impairment Urinary incontinence Chest pain Shortness of breath Severe pallor Fast heartbeat Rejection of baby Suicidal/infanticidal Fever Syncope/dizziness Heavy blood loss Foul smelling discharge Unable to urinate easily Rigors Abnormal coloured urine Soft flabby uterus Discussion Main Findings This study achieved its aims of developing consensus on the key signs and symptoms, predictive of maternal morbidity and mortality in the immediate postnatal period (first 24 hours following birth), that could be self-assessed by mothers supported by their birth companions. A list of 19 key signs and symptoms, spanning seven condition categories (postpartum haemorrhage, genital tract sepsis, cardiovascular disease, preeclampsia/eclampsia, urinary dysfunction, anaemia, postpartum psychosis), was developed. The research team believe this to be the first evidence-based self-care strategy for use in the immediate postnatal period to be developed. Strengths and Limitations The study has several strengths. First, a mixed methods approach was designed. A three-step systematic scoping review identified an expansive list of signs and symptoms from CPGs. Quality assessment was completed using the AGREE II tool to ensure only signs and symptoms from reputable guidelines were included. 16 The Delphi method enabled the involvement of a diverse range of lay and professional stakeholders from geographically distant regions. The use of snowball recruitment using the social media platforms was a useful method of recruitment. Over 90% of participants had at least two years of professional experience. Although the study was led by a UK based research team, there was representation from higher income settings and lower to middle income settings within the Expert Committee and Delphi respondents to enhance the generalisability of the results. The Delphi process also enabled participants to consider the views of others and develop their own opinions. Discussion and debate by the Expert Committee led to further refinement and agreement of the final tool. There are several limitations to consider. First, although there was a large participation in the survey, representation from each stakeholder group was not evenly distributed with 93% of respondents being health workers in round 2 and there was only one patient representative in round 1. It is likely that some participants belonged to more than one stakeholder group, but data are not available to explore this further. Secondly, no signs and symptoms were deemed “not important” during the Delphi process and could be removed. This is unsurprising as all signs and symptoms were retrieved from international recommendations and as such will all be somewhat important at the very least. The limits for consensus were developed a priori and in line with existing Delphi studies. 14 , 17 It might however have been prudent to have developed a limit for the ‘somewhat important’ category too or utilised an alternate method for rating such as ranking of outcomes. Interpretation The four conditions with the highest number of recommendations associated were postpartum haemorrhage, pre-eclampsia/eclampsia, genital tract sepsis and anaemia. Global findings indicate that PPH, Pre-eclampsia/eclampsia and genital tract sepsis account for more than half of maternal deaths worldwide. 18 Additionally, anaemia is widely regarded as a risk factor for worsening outcomes in those experiencing PPH. 18 Given the high morbidity and mortality associated with these conditions, it would seem logical that more guidelines are available that focus on them. However, most guidelines are specifically for high income settings. This is problematic given that the highest maternal morbidity and mortality occurs in LMIC’s. Additionally, there were few country-specific recommendations which are critical to implementing guidelines into clinical practice. Absence of national guidelines and local protocols in maternal health in LMIC’s has been highlighted as a key barrier preventing implementation of high-quality care. 19 Contextualised guidelines, to promote and support consistent delivery of high-quality care in these settings, are urgently needed. There were no CPGs focussing solely on the immediate postnatal period. Of the 44 guidelines included in the review, only 25% (11 guidelines) were specified for the postnatal period. Most guidelines covered the antenatal, intrapartum and postnatal period. This was highlighted in a previous systematic review, with only six international guidelines focussing specifically on postnatal care. 20 Over the past decade, there has been a move to promote continuity of care, through integration of services. The benefits, and improved health outcomes from this approach, are well documented. 19 , 21 However, in addition to integration, there is a need to ensure renewed priority to poorly covered services such as iPNC where the morbidity and mortality is greatest. 21 , 22 Development of specific clinical guidelines on postnatal care would provide the much-needed focus on key health issues, guiding health care providers, programme officers and policy makers in providing comprehensive, high-quality care. The quality of CPGs reviewed varied greatly with a lack of detail and transparency of the development processes by the guideline developers. These findings are consistent with other quality assessments of clinical practice guidelines in maternal care. 20 , 23 , 24 There is a need for guideline development processes to be made explicit, to ensure the content is evidence based and enable practitioners to make informed decisions about whether to adopt the guidance. There is a paucity of literature on danger signs and symptoms specifically within the first 24 hours of birth. For example, the 2022 WHO postnatal care guidelines and the Ugandan Clinical Guidelines only mention danger signs and symptoms for ongoing counselling beyond the first 24 hours of birth. 25 , 26 Within the WHO guidance for ongoing counselling, four conditions were mentioned (postpartum haemorrhage, pre-eclampsia/eclampsia, infection, and thrombo-embolism), and all except thromboembolism have been considered within the list of signs and symptoms. Thromboembolism was considered but disregarded by the Expert Committee as they were reported to be unlikely to occur in the first 24 hours after birth. From the three included categories, all signs and symptoms aligned with those described in the WHO signs and symptoms except epigastric abdominal pain. In the Delphi Survey only 66% of participants ranked this symptom category as critically important and as such it was excluded during sensitivity analysis. The three conditions with the highest number of recommendations associated were postpartum haemorrhage, pre-eclampsia/eclampsia and genital tract sepsis which makes sense, as global findings indicate that these three conditions together account for more than half of maternal deaths worldwide. 18 Despite the risk of maternal mortality and morbidity, after caesarean birth, being five times higher than following vaginal birth, there were no CPGs for assessing signs and symptoms following caesarean birth. 27 – 29 Only one sign/symptom mentioned caesarean birth, and this was blood loss greater than 1000mls for postpartum haemorrhage. Interestingly, experts in postnatal care highlighted the need for inclusion of signs and symptoms specific to caesarean birth, both during discussions with the Expert Committee and during the Delphi Survey. Given the higher risks of morbidity and mortality associated with caesarean section, there is a need for specific guidance on the assessment of signs and symptoms following caesarean births. This should be separate to that for vaginal birth. When preparing for the Delphi Surveys, there were often multiple ways to describe each sign and symptom based on differing country or setting. The need for careful attention of the language and phrasings used in a recommendation document is highlighted within the WHO handbook for guideline development. 30 Literature has reported on the pitfalls occurring particularly with patient reported tools, where poor language choices can lead to misinterpretation of signs and symptoms. 31 It is therefore imperative that beyond securing the signs and symptoms, attention is taken to ensure the phrasing and language used for the signs and symptoms are context specific to each setting. Conclusion International expert consensus was achieved on a list of 19 key signs and symptoms spanning six condition categories that are important and deemed possible that mothers supported by their birth companions could assess in the first 24 hours postnatally. Further work is needed to ensure that this proposed list is adapted to individual regional and country settings to meet the needs of the women and birth companions in such settings in the context of self-monitoring in the immediate postnatal period. Declarations Ethics approval and consent to participate All members of the Expert Committee were approached for participation by email providing information of the study. No members declined participation. No renumeration was made to the Expert Committee for their time and contribution to the study. All members who participated in the Delphi survey were provided information about the study on the survey link. Members provided consent through the survey link. No renumeration was made to the Delphi respondents for their time and contribution to the study. Consent for publication Not applicable Availability of data and materials Not applicable Competing interests The authors declare that they have no competing interests Funding Funding for this project was through the University of Liverpool Research and Development Scheme. The funders did not have a role in the conduct of the research. Authors' contributions TD, TL and ADW devised the project and methodology. TD and NB conducted the analysis. TD produced the first draft manuscript with input from all authors (TD, NB,AH,LB, MM,EVL, SO, TL, ADW). Acknowledgements The authors acknowledge the invaluable contribution from the Delphi respondents during the Delphi Consensus Building process. References Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023. WHO. 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A NATA consensus statement: A multidisciplinary consensus statement. Blood Transfusion. 2019; 17 : 112–36. Muñoz M, Peña-Rosas JP, Robinson S, Milman N, Holzgreve W, Breymann C, et al. Patient blood management in obstetrics: management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period: NATA consensus statement. Transfusion Medicine. 2018; 28 : 22–39. Jacobs A, Abou-Dakn M, Becker K, Both D, Gatermann S, Gresens R, et al. S3-guidelines for the treatment of inflammatory breast disease during the lactation period. Geburtshilfe Frauenheilkd. 2013; 73 : 1202–8. Ministry of Health New Zealand. Observation of Mother and Baby in the Immediate Postnatal Period: Consensus statements guiding practice [Internet]. 2012 https://www.midwife.org.nz/wp-content/uploads/2019/06/observation-mother-baby-immediate-postnatal-period-consensus-statements.pdf [Accessed 2 nd May 2024] NICE. Antenatal and postnatal mental health: clinical management and service guidance [Internet]. 2020. Available from: https://www.nice.org.uk/guidance/cg192 [Accessed 2 nd May 2024] NICE. Postnatal care up to 8 weeks after birth [Internet]. 2006. Available from: www.nice.org.uk/guidance/cg37. [Accessed 2 nd May 2024] NICE. Hypertension in pregnancy: diagnosis and management [Internet]. 2019. Available from: https://www.nice.org.uk/guidance/ng133 [Accessed 2 nd May 2024] RANZCOG. Mental Health Care in the Perinatal Period- Australian Clinical Practice Guideline [Internet]. 2017. Available from: https://cope.org.au/wp-content/uploads/2017/10/Final-COPE-Perinatal-Mental-Health-Guideline.pdf [Accessed 2 nd May 2024] RCOG. Good Practice No. 14 Management of Women with Mental Health Issues during Pregnancy and the Postnatal Period [Internet]. 2011. Available from: https://www.rcog.org.uk/guidance/browse-all-guidance/good-practice-papers/management-of-women-with-mental-health-issues-during-pregnancy-and-the-postnatal-period-good-practice-no14/ [Accessed 2 nd May 2024] RCOG. Bacterial Sepsis following Pregnancy Green-top Guideline No. 64b [Internet]. 2012. Available from: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/bacterial-sepsis-following-pregnancy-green-top-guideline-no-64b/ [Accessed 2 nd May 2024] RCOG. Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52. BJOG . 2017; 124 (5):e106-e149. RCOG. Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management Green-top Guideline No. 37b [Internet]. 2015. Available from: https://www.rcog.org.uk/media/wj2lpco5/gtg-37b-1.pdf [Accessed 2 nd May 2024] SIGN. Management of perinatal mood disorders SIGN 127 [Internet]. 2012. Available from: https://www.sign.ac.uk/assets/sign127_update.pdf [Accessed 2 nd May 2024] SOGP. Recommendation for the Diagnosis and Management of Iron Deficiency Anaemia in Pregnancy and Postpartum [Internet]. 2018. Available from: http://sogp.org/assets/frontend/uploads/guidelines/8.Diagnosis_and_Management_of_Iron_Deficiency_Anaemia_in_Pregnancy.pdf [Accessed 2 nd May 2024] Bowyer L, Robinson HL, Barrett H, Crozier TM, Giles M, Idel I, et al. SOMANZ guidelines for the investigation and management sepsis in pregnancy. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2017; 57 : 540–51. Lowe SA, Bowyer L, Lust K, McMahon LP, Morton M, North RA, et al . SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014. Aust N Z J Obstet Gynaecol . 2015; 55 (5): e1-29. McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S, et al. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Aust N Z J Obstet Gynaecol . 2012; 52 : 14–22. SFOG. Hypertensive diseases during pregnancy [Internet]. 2019. Available from: https://www.sfog.se/start/kunskapsstoed/obstetrik/preeklampsi/ [Accessed 2 nd May 2024] The Joint Comission. Provision of Care, Treatment, and Services standards for maternal safety [Internet]. 2019. Available from: https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_24_maternal_safety_hap_9_6_19_final1.pdf [Accessed 2 nd May 2024] Fuller GW, Nelson-Piercy C, Hunt BJ, Lecky FE, Thomas S, Horspool K, et al. Consensus-derived clinical decision rules to guide advanced imaging decisions for pulmonary embolism in pregnancy and the postpartum period. European Journal of Emergency Medicine . 2018; 25 : 221–2. WHO. Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice. 3 rd Edition. [Internet]. Available from: https://www.who.int/publications/i/item/9789241549356 [Accessed 2 nd May 2024] WHO. 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Supplementary Files Appendix.docx Cite Share Download PDF Status: Published Journal Publication published 28 Mar, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 20 Feb, 2025 Reviews received at journal 19 Feb, 2025 Reviews received at journal 18 Feb, 2025 Reviewers agreed at journal 01 Feb, 2025 Reviewers agreed at journal 31 Jan, 2025 Reviewers agreed at journal 31 Jan, 2025 Reviews received at journal 30 Jan, 2025 Reviewers agreed at journal 30 Jan, 2025 Reviewers agreed at journal 30 Jan, 2025 Reviewers agreed at journal 20 Aug, 2024 Reviewers invited by journal 06 Aug, 2024 Editor invited by journal 12 May, 2024 Editor assigned by journal 07 May, 2024 Submission checks completed at journal 07 May, 2024 First submitted to journal 02 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Medicine","correspondingAuthor":false,"prefix":"","firstName":"Matthews","middleName":"","lastName":"Mathai","suffix":""},{"id":301679246,"identity":"0cb6b286-1bbf-4bd7-8b75-d81079c3479e","order_by":5,"name":"Etienne Langlois","email":"","orcid":"","institution":"PMNCH","correspondingAuthor":false,"prefix":"","firstName":"Etienne","middleName":"","lastName":"Langlois","suffix":""},{"id":301679247,"identity":"3c2cbc8e-ef1a-4642-abb6-922a53c5b1dd","order_by":6,"name":"Sam Ononge","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Sam","middleName":"","lastName":"Ononge","suffix":""},{"id":301679248,"identity":"de6a54ee-f88c-46d0-9cfd-9160ab475aa7","order_by":7,"name":"Tina Lavender","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tina","middleName":"","lastName":"Lavender","suffix":""},{"id":301679249,"identity":"e76c6cfd-246b-4293-b156-2f6ea1aadc19","order_by":8,"name":"Andrew Weeks","email":"","orcid":"","institution":"University of Liverpool","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Weeks","suffix":""}],"badges":[],"createdAt":"2024-05-02 09:49:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4358269/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4358269/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-07472-9","type":"published","date":"2025-03-28T15:57:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56457089,"identity":"56e21f18-e72f-4032-bbc0-d68d83b23c1a","added_by":"auto","created_at":"2024-05-14 12:25:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":200262,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eData flow chart for Expert Committee discussion\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4358269/v1/91b251a428658eec4dc18cc9.png"},{"id":79605001,"identity":"8bddbd1a-f3f8-4d9c-aec8-2ff2ef9548b2","added_by":"auto","created_at":"2025-03-31 16:10:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1074108,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4358269/v1/af325781-4bb5-4086-8b58-d8471748623e.pdf"},{"id":56457091,"identity":"d2283f9d-8a4b-4863-9ce6-73a8f109499f","added_by":"auto","created_at":"2024-05-14 12:25:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":233100,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-4358269/v1/2a7810bc7eafe02bcca59dad.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Critical signs and symptoms for self-assessment in the immediate postnatal period: an international Systematic Scoping Review and Delphi consensus study","fulltext":[{"header":"Background","content":"\u003cp\u003eAccording to the latest United Nations (UN) estimates, a woman dies from complications of pregnancy and childbirth every two minutes.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Most maternal mortality occurs within the first 24 hours and a focus on immediate postnatal care (iPNC) is therefore important.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite its lifesaving value, postnatal care is critically neglected. One in five mothers and babies do not have access to life-saving postnatal care interventions.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Furthermore, the COVID-19 pandemic resulted in increasing fragmentation and disruption of essential reproductive health services including postnatal care. There is an urgent need for new and innovative strategies for postnatal care to ensure the accelerated reduction in global maternal deaths needed to achieve the Sustainable Development Goal Target 3.1 by 2030.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRecent global crises have highlighted self-care strategies as effective mechanisms to ensure continued provision of services, promote women centred care and achieve universal health coverage. As such the World Health Organization (WHO) has made a call for strategies and interventions that promote self-care.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Yet within the existing list of self-care interventions, there is a lack of strategies for self-monitoring in the immediate postnatal period by mothers, supported by their birth companions, in health facilities.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDeveloping self-monitoring strategies requires an understanding of the key signs and symptoms and whether these could be easily assessed by mothers and birth companions in the immediate postnatal period. To date, there is no existing research nor consensus on this.\u003c/p\u003e \u003cp\u003eThe objective of this study was to achieve international consensus on a list of key immediate postnatal signs and symptoms that are predictive of maternal morbidity and which mothers, or their birth companions could self-assess in health facilities during the immediate postnatal period, without the need for additional equipment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA multi-step approach was utilised for this process including systematic scoping review, expert review and Delphi survey. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProcess for establishing content of the Immediate Postnatal Women\u0026rsquo;s Assessment (ImPoWA) tool\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAims\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMethods\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic scoping literature review to generate a comprehensive list of signs and symptoms that clinical practice guidelines suggest should be assessed in the immediate postnatal period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSystematic scoping literature review\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview of systematic scoping review findings to agree on the content validity of key signs and symptoms for inclusion in Delphi Survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpert Committee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup Discussion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRating of the importance of signs and symptoms, and suggestion of any new additions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDelphi respondents (identified through snowball sampling)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDelphi Survey\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRepeat of step 3 with the refined list\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInvitations to same Delphi respondents as in step 3 above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDelphi Survey\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview of unresolved signs and symptoms, and achieving final consensus on tool content.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpert Committee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup Discussion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStep 1: Systematic Scoping Review\u003c/h2\u003e \u003cp\u003e A systematic scoping review was undertaken to identify a comprehensive list of signs and symptoms that international clinical practice guidelines (CPG\u0026rsquo;s) suggest should be assessed within the immediate postnatal period. The review question was broad and as such PROSPERO advised the authors to conduct a scoping review. That said, the authors were committed to conduct the review rigorously and adopt a systematic approach. As such, the review was also conducted in accordance with PRISMA guidelines.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe most recent versions of CPGs, available in English and published between January 2010 and June 2020, were included. Guidelines were excluded that were not specific to postnatal mothers or did not specify signs or symptoms to be assessed during the postnatal period. Primary and secondary research studies, conference abstracts, locally created CPGs, or those focusing on COVID-19 were excluded.\u003c/p\u003e \u003cp\u003eA three-step search strategy was used (Appendix 1). Firstly, a comprehensive search of 15 published and three unpublished databases electronic databases was conducted. Secondly, a search of maternal health professional organisations and societies websites was conducted. Thirdly, the reference lists of selected guidelines were reviewed to identify additional CPGs.\u003c/p\u003e \u003cp\u003eTitle and abstract screening was conducted by one reviewer (NB). Full text screening was conducted by two reviewers (TD, NB), with a third reviewer (ADW) available to discuss any disagreements. Data was extracted by TD and NB in duplicate to a pre-created data extraction form. Signs and symptoms were transcribed literally before being organised into categories according to the clinical condition they related to, based on clinical opinion. Any duplicated signs or symptoms were removed at this stage.\u003c/p\u003e \u003cp\u003e The quality of included CPGs was assessed by two reviewers (TD, NB) using the AGREE II tool with a third reviewer (ADW) consulted to discuss discrepancies. \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In line with previous literature, a score of \u0026gt;\u0026thinsp;60% for each domain was considered sufficient.\u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Finally, two reviewers (TD, NB) provided an overall assessment of each guideline, using the following parameters:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u0026lsquo;Recommended\u0026rsquo; was assigned if most domains (four or more) scored above 60%.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u0026lsquo;Recommended with modifications\u0026rsquo; was assigned if most domains (four or more) scored between 30\u0026ndash;60%.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u0026lsquo;Not recommended\u0026rsquo; was assigned to any guidelines where most (four of more) of the domains scored below 30%.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003cp\u003e Guidelines listed as \u0026lsquo;recommended\u0026rsquo; or \u0026lsquo;recommended with modifications\u0026rsquo; were selected for inclusion. Those guidelines listed as not recommended were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStep 2: Expert Committee\u003c/h2\u003e \u003cp\u003eA committee of nine experts was purposively selected from members of international and national groups focused on optimising postnatal care provision and uptake (Appendix 2).\u003c/p\u003e \u003cp\u003e The Expert Committee reviewed the systematic scoping review findings to assess content validity. Discussions focused on three questions:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eHow likely are these signs and symptoms to occur in the first 24 hours following birth?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHow essential or likely is the sign or symptom to predict maternal morbidity and morbidity within 24 hours of birth?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCan the sign or symptom be easily assessed by a mother or her birth companion without extensive training?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe Expert Committee were invited to suggest any additional signs and symptoms they deemed pertinent for inclusion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStep 3 and 4: Delphi Survey\u003c/h2\u003e \u003cp\u003eA two-round anonymised electronic Delphi Survey was designed on Joint Information Systems Committee (JISC) software.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e E-mail invitations, including a link to the Delphi Survey, were sent to relevant contacts of the research team to participate in the study. Invitees were encouraged to share the survey in their network resulting in snowball recruitment. The survey was also advertised through social media to gain a global response. Newly identified participants were sent personal e-mail invitations to participate in the study including a link to the survey.\u003c/p\u003e \u003cp\u003eThere are no clear guidelines on sample size calculations required for a Delphi Survey.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Previous models have suggested that a minimum of five in each area of expertise would be sufficient to be provide content validity and varied input to produce meaningful and generalisable results.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Initial stakeholder mapping identified four key stakeholder groups to be included (Clinicians, Academics/Researchers, Public Health officers and programmers, Women\u0026rsquo;s Representatives). The researchers aimed towards a minimum sample size of 50 participants to account for potential attrition in Round 2 and likelihood of respondents crossing stakeholder groups.\u003c/p\u003e \u003cp\u003eDuring the Delphi Survey, participants were asked to rate the importance and possibility for mothers and birth companions to assess each of the signs and symptoms. Participants were asked to rate between 1 and 7 on a Likert scale with 1\u0026ndash;2 being \u0026lsquo;not important\u0026rsquo;, 3\u0026ndash;5 being \u0026lsquo;important but not critical\u0026rsquo; and 6\u0026ndash;7 being \u0026lsquo;critically important\u0026rsquo;. Participants had the option to select \u0026ldquo;unable to comment\u0026rdquo;.\u003c/p\u003e \u003cp\u003eIn round 1, a free-text option enabled participants to suggest additional signs and symptoms that were not already listed.\u003c/p\u003e \u003cp\u003eConsensus for the Delphi Survey was defined \u003cem\u003ea priori\u003c/em\u003e based on the limits used to develop the core outcome sets.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e In this study, for an item to have achieved full consensus and be termed \u0026lsquo;critically important\u0026rsquo;, at least 75% of participants needed to score the item as \u0026lsquo;critically important\u0026rsquo; with \u0026lt;\u0026thinsp;15% of participants scoring the item as \u0026lsquo;not important\u0026rsquo;. Items that did not achieve consensus and were scored \u0026lsquo;not important\u0026rsquo; required at least 75% of participants to score it as such and \u0026lt;\u0026thinsp;15% to score the item as \u0026lsquo;critically important\u0026rsquo;. Any items not meeting either category would have achieved some consensus and be termed \u0026ldquo;somewhat important\u0026rdquo;.\u003c/p\u003e \u003cp\u003eA sensitivity analysis was conducted for signs and symptoms graded as \u0026ldquo;somewhat important\u0026rdquo;. Signs and symptoms with similar phrasings were arranged under a specific sign/symptom category irrespective of condition. The highest score each respondent attributed to any of the signs and symptoms within that category was recorded. Each sign and symptom was graded using the Likert scale, as above.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eFirst round of the Delphi Survey\u003c/h2\u003e \u003cp\u003eThe first Delphi Survey was open for four weeks. Two reminder emails were sent to non-responders across the survey period.\u003c/p\u003e \u003cp\u003eDuring the first round of the Delphi Survey, no signs or symptoms could be excluded. An additional 10 signs and symptoms were suggested by the respondents and added, resulting in a new questionnaire with 144 signs and symptoms for the second round of the Delphi Survey.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSecond round of the Delphi Survey\u003c/h2\u003e \u003cp\u003eResponders to the first Delphi survey were also invited to participate in the second round. No new participants were invited at this stage and non-responders from round 1 were not invited to participate in round 2.\u003c/p\u003e \u003cp\u003eIn Round 2, the revised questionnaire containing the 144 signs and symptoms was emailed directly to the Round 1 Delphi respondents. Within the survey, participants were provided with the results from round 1 (percentage of participants rating each sign or symptom as critically important), based on Delphi methodology. This enabled those receiving the survey to reflect on existing responses before completing round 2.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe Delphi Survey closed 4 weeks after the start of round 2 and weekly reminder emails were sent until closure of the questionnaire.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStep 5: Consultation meeting\u003c/h2\u003e \u003cp\u003eThe Expert Committee met to discuss the results of round 1 and 2 of the Delphi Survey. Prior to the meeting, the committee were provided with the collated results from both rounds of the survey. The committee members were asked to prioritise the list of key signs and symptoms deemed most critical (\u0026gt;\u0026thinsp;75% or above). Duplicates, those considered difficult for the mothers and birth companions to assess, and those occurring over 24 hours after birth were removed from the list. Next the list of signs and symptoms deemed \u0026lsquo;somewhat critical\u0026rsquo; were reviewed. Duplicates, and those considered difficult for the mothers and birth companions to assess, were removed from the list. Finally, the committee reviewed all results to reach a final consensus on the key signs and symptoms that could be self-assessed by mothers, with the support of their birth companions.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003e for this study was gained through University of Liverpool Ethical Review Committee (Ref: 9743).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003eStep 1: Systematic scoping review\u003c/h2\u003e\n \u003cp\u003eA total of 20,734 articles relevant to iPNC were identified (Appendix 3) were screened. Forty-four CPGs were identified, which met eligibility criteria, and were included in the review (Appendix 4). Of these guidelines, 13 were intended for an international audience, 30 were specifically for high income countries and six were created for low- and middle-income country (LMIC) settings. Only 11 guidelines were specifically for the postnatal period.\u003c/p\u003e\n \u003cp\u003eA total of 351 maternal signs and symptoms, across 12 condition categories pertaining to the immediate postnatal period, were identified.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003eStep 2: Expert Committee\u003c/h2\u003e\n \u003cp\u003eThe Expert Committee reviewed the initial list of 351 signs and symptoms for content validity. One duplicate was removed, and 232 signs and symptoms were excluded. One hundred and seven were deemed unlikely to occur within the first 24 hours of birth; 45 were not considered essential for predicting maternal morbidity and mortality; and 79 were considered unsuitable for assessment by a mother or her birth companion, without additional equipment. Alternative phrasing was proposed for six signs and symptoms that had previously been excluded and as such were re-added. An additional nine signs/symptoms were suggested. Discussions resulted in the creation of a list of 134 signs and symptoms, arranged in seven condition categories, to be reviewed during the first round of the Delphi Survey (Appendix 5).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eSteps 3 and 4: Delphi Survey\u003c/h2\u003e\n \u003cp\u003eOne hundred and thirteen respondents, from 10 countries, completed round one of the Delphi Survey. Fifty-nine of these respondents, from nine countries, subsequently completed round two (52%) Most of the round two respondents (94%) were practising health care workers (Table \u003cspan\u003e2\u003c/span\u003e). Most respondents had been working in clinical practice for at least 5 years. There were 51% of respondents from high-income-settings, 37% from lower-middle-income settings and 12% from low-income settings.\u0026nbsp;\u003c/p\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eDemographics of Delphi respondents\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRound 1 (n\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRound 2 (n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRole\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcademics/researchers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic Health officers and programmers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWomen\u0026rsquo;s representatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Duty\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u0026ndash;4 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 year or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNigeria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUganda\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKenya\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNepal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTanzania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGhana\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eStep 5: Expert Committee\u003c/h2\u003e\n \u003cp\u003eWhen reviewing the results of each round of the Delphi Survey, the Expert Committee highlighted the value of a broad list of signs and symptoms, not limited to specific conditions occurring in the postnatal period, given that many signs and symptoms span multiple conditions. Of the 144 signs and symptoms reviewed in round 2 of the Delphi survey, 35 (24%) were considered \u0026lsquo;critically important\u0026rsquo;; 109 (76%) \u0026lsquo;somewhat important\u0026rsquo;; and none were deemed unimportant or excluded (Fig. \u003cspan\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lsquo;Critically important\u0026rsquo; signs and symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOf the 35 most critically important signs, the Expert Committee excluded 23 of them. Thirteen were duplicates; 10 were deemed difficult for a mother and birth companion to assess without training and equipment or would occur after 24 hours following birth. Twelve were selected for inclusion in the list of key signs and symptoms. These included, \u0026ldquo;change in consciousness, seizure, severe headache, persistent visual impairment, urinary incontinence, chest pain, shortness of breath, severe pallor, fast heartbeat, rejection of baby, suicidal/infanticidal, fever\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lsquo;Somewhat important\u0026rsquo; signs and symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFor the 109 somewhat important signs and symptoms, a sensitivity analysis was conducted. Ten signs and symptoms categories contained at least one sign or symptom that was scored as \u0026ldquo;critically important\u0026rdquo; by more than 75% of respondents. These were dizziness, amount of blood loss, foul smelling discharge, hallucinations/delusions, inability to pass urine, depression, rigors, lethargy, coloured urine and soft flabby uterus. Fifty-four signs and symptoms were listed within the ten sign and symptoms categories and excluded as duplicates. Forty-five signs and symptoms were not housed within the ten important signs and symptoms categories and excluded as deemed not important.\u003c/p\u003e\n \u003cp\u003eThe Expert Committee advised renaming two of the signs and symptoms for clarity. Coloured urine was renamed \u0026ldquo;abnormally coloured urine\u0026rdquo;, and amount of blood loss was renamed \u0026ldquo;heavy blood loss\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003eThree signs and symptoms; \u0026ldquo;lethargy\u0026rdquo;, \u0026ldquo;hallucinations and delusions\u0026rdquo; and \u0026ldquo;depression\u0026rdquo; were excluded as the Expert Committee considered them to be difficult for a mother and birth companion to assess.\u003c/p\u003e\n \u003cp\u003eA final list of 19 signs and symptoms that were important and possible to be assessed in the immediate postnatal period were selected as below:\u003c/p\u003e\n \u003cdiv align=\"left\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChange in consciousness\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeizure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere Headache\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersistent visual impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrinary incontinence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChest pain\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShortness of breath\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere pallor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFast heartbeat\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRejection of baby\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicidal/infanticidal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSyncope/dizziness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeavy blood loss\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFoul smelling discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnable to urinate easily\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRigors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbnormal coloured urine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSoft flabby uterus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \n\u003c/div\u003e\n"},{"header":"Discussion","content":"\u003ch2\u003eMain Findings\u003c/h2\u003e\u003cp\u003eThis study achieved its aims of developing consensus on the key signs and symptoms, predictive of maternal morbidity and mortality in the immediate postnatal period (first 24 hours following birth), that could be self-assessed by mothers supported by their birth companions. A list of 19 key signs and symptoms, spanning seven condition categories (postpartum haemorrhage, genital tract sepsis, cardiovascular disease, preeclampsia/eclampsia, urinary dysfunction, anaemia, postpartum psychosis), was developed. The research team believe this to be the first evidence-based self-care strategy for use in the immediate postnatal period to be developed.\u003c/p\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eThe study has several strengths. First, a mixed methods approach was designed. A three-step systematic scoping review identified an expansive list of signs and symptoms from CPGs. Quality assessment was completed using the AGREE II tool to ensure only signs and symptoms from reputable guidelines were included.\u003csup\u003e\u003cspan citationid=\"CR16\"\u003e16\u003c/span\u003e\u003c/sup\u003e The Delphi method enabled the involvement of a diverse range of lay and professional stakeholders from geographically distant regions. The use of snowball recruitment using the social media platforms was a useful method of recruitment. Over 90% of participants had at least two years of professional experience. Although the study was led by a UK based research team, there was representation from higher income settings and lower to middle income settings within the Expert Committee and Delphi respondents to enhance the generalisability of the results. The Delphi process also enabled participants to consider the views of others and develop their own opinions. Discussion and debate by the Expert Committee led to further refinement and agreement of the final tool.\u003c/p\u003e\u003cp\u003eThere are several limitations to consider. First, although there was a large participation in the survey, representation from each stakeholder group was not evenly distributed with 93% of respondents being health workers in round 2 and there was only one patient representative in round 1. It is likely that some participants belonged to more than one stakeholder group, but data are not available to explore this further. Secondly, no signs and symptoms were deemed “not important” during the Delphi process and could be removed. This is unsurprising as all signs and symptoms were retrieved from international recommendations and as such will all be somewhat important at the very least. The limits for consensus were developed \u003cem\u003ea priori\u003c/em\u003e and in line with existing Delphi studies.\u003csup\u003e\u003cspan citationid=\"CR14\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR17\"\u003e17\u003c/span\u003e\u003c/sup\u003e It might however have been prudent to have developed a limit for the ‘somewhat important’ category too or utilised an alternate method for rating such as ranking of outcomes.\u003c/p\u003e\u003ch2\u003eInterpretation\u003c/h2\u003e\u003cp\u003eThe four conditions with the highest number of recommendations associated were postpartum haemorrhage, pre-eclampsia/eclampsia, genital tract sepsis and anaemia. Global findings indicate that PPH, Pre-eclampsia/eclampsia and genital tract sepsis account for more than half of maternal deaths worldwide.\u003csup\u003e\u003cspan citationid=\"CR18\"\u003e18\u003c/span\u003e\u003c/sup\u003e Additionally, anaemia is widely regarded as a risk factor for worsening outcomes in those experiencing PPH.\u003csup\u003e\u003cspan citationid=\"CR18\"\u003e18\u003c/span\u003e\u003c/sup\u003e Given the high morbidity and mortality associated with these conditions, it would seem logical that more guidelines are available that focus on them. However, most guidelines are specifically for high income settings. This is problematic given that the highest maternal morbidity and mortality occurs in LMIC’s. Additionally, there were few country-specific recommendations which are critical to implementing guidelines into clinical practice. Absence of national guidelines and local protocols in maternal health in LMIC’s has been highlighted as a key barrier preventing implementation of high-quality care.\u003csup\u003e\u003cspan citationid=\"CR19\"\u003e19\u003c/span\u003e\u003c/sup\u003e Contextualised guidelines, to promote and support consistent delivery of high-quality care in these settings, are urgently needed.\u003c/p\u003e\u003cp\u003eThere were no CPGs focussing solely on the immediate postnatal period. Of the 44 guidelines included in the review, only 25% (11 guidelines) were specified for the postnatal period. Most guidelines covered the antenatal, intrapartum and postnatal period. This was highlighted in a previous systematic review, with only six international guidelines focussing specifically on postnatal care.\u003csup\u003e\u003cspan citationid=\"CR20\"\u003e20\u003c/span\u003e\u003c/sup\u003e Over the past decade, there has been a move to promote continuity of care, through integration of services. The benefits, and improved health outcomes from this approach, are well documented.\u003csup\u003e\u003cspan citationid=\"CR19\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR21\"\u003e21\u003c/span\u003e\u003c/sup\u003e However, in addition to integration, there is a need to ensure renewed priority to poorly covered services such as iPNC where the morbidity and mortality is greatest.\u003csup\u003e\u003cspan citationid=\"CR21\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\"\u003e22\u003c/span\u003e\u003c/sup\u003e Development of specific clinical guidelines on postnatal care would provide the much-needed focus on key health issues, guiding health care providers, programme officers and policy makers in providing comprehensive, high-quality care.\u003c/p\u003e\u003cp\u003e The quality of CPGs reviewed varied greatly with a lack of detail and transparency of the development processes by the guideline developers. These findings are consistent with other quality assessments of clinical practice guidelines in maternal care.\u003csup\u003e\u003cspan citationid=\"CR20\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR23\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\"\u003e24\u003c/span\u003e\u003c/sup\u003e There is a need for guideline development processes to be made explicit, to ensure the content is evidence based and enable practitioners to make informed decisions about whether to adopt the guidance.\u003c/p\u003e\u003cp\u003eThere is a paucity of literature on danger signs and symptoms specifically within the first 24 hours of birth. For example, the 2022 WHO postnatal care guidelines and the Ugandan Clinical Guidelines only mention danger signs and symptoms for ongoing counselling beyond the first 24 hours of birth. \u003csup\u003e\u003cspan citationid=\"CR25\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\"\u003e26\u003c/span\u003e\u003c/sup\u003e Within the WHO guidance for ongoing counselling, four conditions were mentioned (postpartum haemorrhage, pre-eclampsia/eclampsia, infection, and thrombo-embolism), and all except thromboembolism have been considered within the list of signs and symptoms. Thromboembolism was considered but disregarded by the Expert Committee as they were reported to be unlikely to occur in the first 24 hours after birth. From the three included categories, all signs and symptoms aligned with those described in the WHO signs and symptoms except epigastric abdominal pain. In the Delphi Survey only 66% of participants ranked this symptom category as critically important and as such it was excluded during sensitivity analysis. The three conditions with the highest number of recommendations associated were postpartum haemorrhage, pre-eclampsia/eclampsia and genital tract sepsis which makes sense, as global findings indicate that these three conditions together account for more than half of maternal deaths worldwide.\u003csup\u003e\u003cspan citationid=\"CR18\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDespite the risk of maternal mortality and morbidity, after caesarean birth, being five times higher than following vaginal birth, there were no CPGs for assessing signs and symptoms following caesarean birth.\u003csup\u003e\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\"\u003e27\u003c/span\u003e–\u003cspan citationid=\"CR29\"\u003e29\u003c/span\u003e\u003c/sup\u003e Only one sign/symptom mentioned caesarean birth, and this was blood loss greater than 1000mls for postpartum haemorrhage. Interestingly, experts in postnatal care highlighted the need for inclusion of signs and symptoms specific to caesarean birth, both during discussions with the Expert Committee and during the Delphi Survey. Given the higher risks of morbidity and mortality associated with caesarean section, there is a need for specific guidance on the assessment of signs and symptoms following caesarean births. This should be separate to that for vaginal birth.\u003c/p\u003e\u003cp\u003eWhen preparing for the Delphi Surveys, there were often multiple ways to describe each sign and symptom based on differing country or setting. The need for careful attention of the language and phrasings used in a recommendation document is highlighted within the WHO handbook for guideline development.\u003csup\u003e\u003cspan citationid=\"CR30\"\u003e30\u003c/span\u003e\u003c/sup\u003e Literature has reported on the pitfalls occurring particularly with patient reported tools, where poor language choices can lead to misinterpretation of signs and symptoms.\u003csup\u003e\u003cspan citationid=\"CR31\"\u003e31\u003c/span\u003e\u003c/sup\u003e It is therefore imperative that beyond securing the signs and symptoms, attention is taken to ensure the phrasing and language used for the signs and symptoms are context specific to each setting.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eInternational expert consensus was achieved on a list of 19 key signs and symptoms spanning six condition categories that are important and deemed possible that mothers supported by their birth companions could assess in the first 24 hours postnatally. Further work is needed to ensure that this proposed list is adapted to individual regional and country settings to meet the needs of the women and birth companions in such settings in the context of self-monitoring in the immediate postnatal period.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll members of the Expert Committee were approached for participation by email providing information of the study. No members declined participation. No renumeration was made to the Expert Committee for their time and contribution to the study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All members who participated in the Delphi survey were provided information about the study on the survey link. Members provided consent through the survey link. No renumeration was made to the Delphi respondents for their time and contribution to the study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this project was through the University of Liverpool Research and Development Scheme. The funders did not have a role in the conduct of the research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTD, TL and ADW devised the project and methodology. TD and NB conducted the analysis. TD produced the first draft manuscript with input from all authors (TD, NB,AH,LB, MM,EVL, SO, TL, ADW).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the invaluable contribution from the Delphi respondents during the Delphi Consensus Building process.\u0026nbsp;\u003c/p\u003e"},{"header":"References ","content":"\u003col\u003e\n\u003cli\u003eTrends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023.\u003c/li\u003e\n\u003cli\u003eWHO. 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Available from: https://apps.who.int/iris/handle/10665/255760 [Accessed 2\u003csup\u003end\u003c/sup\u003e May 2024]\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4358269/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4358269/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEvery 2 minutes a woman dies from complications of pregnancy and childbirth. Most maternal deaths occur within the first 24 hours following birth, highlighting the importance of immediate postnatal care (iPNC). Self-care strategies are increasingly being employed to promote women-centred, continuous care provision. Despite international calls for development of strategies promoting self-care, none have been developed for self-monitoring in the immediate postnatal period. Fundamental to the development of a self-monitoring strategy, is an understanding of which signs and symptoms are predictive of maternal morbidity and mortality and can be easily assessed by mothers and birth companions, in health facilities, without the need for equipment. The objective of this study was to develop and achieve international consensus on the key signs and symptoms.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA multi-step approach involving a systematic scoping review, two- round Delphi Survey, and expert consensus was employed to identify key signs and symptoms that can be self- assessed and predict morbidity and mortality in the immediate postnatal period.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e A comprehensive list of 351 key signs and symptoms was identified from 44 clinical practice guidelines. Subsequently, 134 signs and symptoms were reviewed by Delphi respondents and international expert consensus was achieved for 19 key signs and symptoms across seven condition categories. The signs that were considered both important and able to be self-assessed by mothers and birth companions in the first 24 hours following birth included change in consciousness, seizure, severe headache, persistent visual impairment, urinary incontinence, chest pain, shortness of breath, severe pallor, fast heartbeat, rejection of baby, suicidal/infanticidal, fever, heavy blood loss, soft flabby uterus, unable to urinate easily, foul smelling discharge, rigors, syncope/dizziness, abnormal coloured urine.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study identified key signs and symptoms which can be easily assessed by mothers and birth companions in the immediate postnatal period to identify those most at risk of morbidity and mortality. Further work is needed to validate this screening tool, and adapt it for other regions and countries.\u003c/p\u003e","manuscriptTitle":"Critical signs and symptoms for self-assessment in the immediate postnatal period: an international Systematic Scoping Review and Delphi consensus study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-14 12:25:54","doi":"10.21203/rs.3.rs-4358269/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-20T05:53:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-20T04:44:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-18T05:30:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239255336163371207654780401557755500752","date":"2025-02-01T19:17:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73338212192016077687291359262310191121","date":"2025-02-01T01:31:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291155491067376359926570603693365447416","date":"2025-01-31T13:26:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-30T11:04:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270739947504385087898726069944502092760","date":"2025-01-30T06:42:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332683107512003401368530327121956575649","date":"2025-01-30T05:53:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265541694049569096531007657665637316247","date":"2024-08-20T05:54:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-06T09:39:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-12T15:22:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-08T00:48:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-08T00:48:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-05-02T09:42:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a5feae1d-15f7-482b-a0e5-682ef4ae3658","owner":[],"postedDate":"May 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T16:05:32+00:00","versionOfRecord":{"articleIdentity":"rs-4358269","link":"https://doi.org/10.1186/s12884-025-07472-9","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-03-28 15:57:34","publishedOnDateReadable":"March 28th, 2025"},"versionCreatedAt":"2024-05-14 12:25:54","video":"","vorDoi":"10.1186/s12884-025-07472-9","vorDoiUrl":"https://doi.org/10.1186/s12884-025-07472-9","workflowStages":[]},"version":"v1","identity":"rs-4358269","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4358269","identity":"rs-4358269","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}