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Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial.
Reproductive Health. 2013; 10:19.BACKGROUND: In 2001, the WHO Antenatal Care Trial (WHOACT) concluded that an antenatal care package of evidence-based screening, therapeutic interventions and education across four antenatal visits for low-risk women was not inferior to standard antenatal care and may reduce cost. However, an updated Cochrane review in 2010 identified an increased risk of perinatal mortality of borderline statistical significance in three cluster-randomized trials (including the WHOACT) in developing countries. We conducted a secondary analysis of the WHOACT data to determine the relationship between the reduced visits, goal-oriented antenatal care package and perinatal mortality. METHODS: Exploratory analyses were conducted to assess the effect of baseline risk and timing of perinatal death. Women were stratified by baseline risk to assess differences between intervention and control groups. We used linear modeling and Poisson regression to determine the relative risk of fetal death, neonatal death and perinatal mortality by gestational age. RESULTS: 12,568 women attended the 27 intervention clinics and 11,958 women attended the 26 control clinics. 6,160 women were high risk and 18,365 women were low risk. There were 161 fetal deaths (1.4%) in the intervention group compared to 119 fetal deaths in the control group (1.1%) with an increased overall adjusted relative risk of fetal death (Adjusted RR 1.27; 95% CI 1.03, 1.58). This was attributable to an increased relative risk of fetal death between 32 and 36 weeks of gestation (Adjusted RR 2.24; 95% CI 1.42, 3.53) which was statistically significant for high and low risk groups. CONCLUSION: It is plausible the increased risk of fetal death between 32 and 36 weeks gestation could be due to reduced number of visits, however heterogeneity in study populations or differences in quality of care and timing of visits could also be playing a role. Monitoring maternal, fetal and neonatal outcomes when implementing antenatal care protocols is essential. Implementing reduced visit antenatal care packages demands careful monitoring of maternal and perinatal outcomes, especially fetal death.
[Research Triangle Park, North Carolina], FHI, .  p. (Research Brief on Hormonal Contraception)The World Health Organization has changed its recommendation on the timing of re-injection for depot medroxyprogesterone acetate (DMPA). The new guidelines encourage health care providers to allow a longer grace period for a woman to return for her next injection of this popular hormonal contraceptive.
The practice of antenatal care: comparing four study sites in different parts of the world participating in the WHO Antenatal Care Randomised Controlled Trial. [Práctica de controles prenatales: comparación de cuatro centros de estudio en diferentes lugares del mundo que participaron en el Estudio Controlado Aleatorizado de Control Prenatal de la OMS]
Paediatric and Perinatal Epidemiology. 1998; 12 Suppl 2:116-141.In the preparation of a randomised controlled trial to evaluate a new programme of antenatal care (ANC) in different parts of the world, we conducted a baseline survey of the ANC procedures in all 53 clinics participating in the trial. There were two components of this survey: (1) description of clinic characteristics and services offered: the staff of each clinic was interviewed and direct observation was made by field supervisors, and (2) the actual use of services by pregnant women attending these clinics: we reviewed a random sample of 2913 clinical histories. The clinical units surveyed were offering most of the activities, screening, laboratory tests and interventions recommended as effective according to the Cochrane Pregnancy and Childbirth Database (PCD), although some of these were not available in some sites. On the other hand, some tests and interventions that are considered not effective according to these criteria are reportedly offered. There was a difference across sites in the availability and offer to low-risk women of vaginal examination, evaluation of pelvic size, dental examination, external version for breech presentation and formal risk score classification, and a notable difference in the type of principal provider of ANC. There was a large variation in the actual use of screening and laboratory tests and interventions that should be offered to all women according to Cochrane PCD criteria: some of these are simply not available in a site; others are available, but only a fraction of women attending the clinics are receiving them. The participating sites all purport to follow the traditional `Western' schedule for ANC, but in three sites we found that a high percentage of women initiate their ANC after the first trimester, and therefore do not have either the recommended minimum number of visits during pregnancy or the minimum first trimester evaluation. It is concluded that the variability and heterogeneity of ANC services provided in the four study sites are disturbing to the profession and cast doubts on the rationale of routine ANC. (author's)
Geneva, Switzerland, WHO, 1996.  p. (WHO/FRH/MSM/96.8)A Technical Working Group on Antenatal Care was convened in Geneva, 31 October - 4 November 1994, by the World Health Organization. The original objectives of the Technical Working Group were: 1. To review current antenatal care practices and make recommendations for the identification of high-risk pregnancies and their management, taking into account the timing of the pregnancy, resources available, and skills of the health worker; 2. To draw up recommendations on antenatal care and specifically outline the tasks and procedures health workers are expected to perform at different levels of the health care system; 3. To review the basic equipment, procedures, and supplies used in antenatal care from the point of view of cost, maintenance, scientific validity, and skills required to employ them appropriately; 4. To examine how to optimize antenatal care in terms of clinical tasks and procedures in relationship to the timing of the visits, distance to referral centres, and frequency of attendance. (excerpt)
Chicago, Illinois, Planned Parenthood Association of Chicago, 1966. 16 p.Add to my documents.
AIDS. 1998; 12 Suppl 2:S57-65.The World Health Organization's Global Program on AIDS (WHO/GPA) has developed a protocol for conducting facility-based assessments of sexually transmitted disease (STD) case management strategies. The WHO/GPA methodology measures two composite prevention indicators (PIs): PI16--the proportion of patients presenting with STD symptoms who are diagnosed and treated appropriately, and PI17--the proportion who receive basic counseling about condoms and partner notification. The protocol calls for direct observation of provider-client interactions and provider interviews. This article reviews the research literature on the evaluation of STD case management in developing countries. Several studies adapted the WHO/GPA protocol for resource-poor settings and utilized techniques such as record review, patient encounter forms, patient exit interviews, and simulated patients and pharmacy shoppers. Overall, experience indicates that it is difficult to implement the protocol as intended in all field situations. Although nonstandardized alternative methods of data collection do not provide a composite PI16 score, they do generate rich data for monitoring the quality of STD case management and contribute to managerial and supervisory aspects of intervention programs. A widespread observation was that providers have the knowledge to provide better quality STD care than they do in actual practice.
STUDIES IN FAMILY PLANNING. 1994 Nov-Dec; 25(6 Pt 1):362-7.International Program in Population and Family Planning, Pathfinder International, and other organizations providing support to family planning organizations in developing countries, generally recommend that women who use intrauterine devices (IUDs) go for an initial revisit at four to six weeks postinsertion, a second revisit at one year, and subsequent revisits at yearly intervals. However, ministries of health and family planning organizations in developing countries generally recommend more frequent revisits. This study examined the effect of reducing the recommended number of IUD follow-up visits using data from clinical trials of the TCu380A and other widely used IUDs conducted by Family Health International (FHI) during 1986-89. The clinical studies were conducted in 13 clinics in 9 countries (Cameroon, Egypt, El Salvador, Mexico, Pakistan, Peru, Philippines, Sri Lanka, and Venezuela) among sexually active and healthy women aged 18-40. Over 11,000 follow-up forms were analyzed to estimate the number of health problems that would escape detection if women with no or mild symptoms had not made recommended visits. Less than 1% of woman-visits with no or only mild symptoms had an underlying health risk that could have gone undetected if the follow-up visits that were made in the clinic trial setting had not been made. Results suggest that a reduction in the number of recommended follow-up visits is safe, when measured according to selected conditions. Clinic policy and practice in family planning probably could move toward encouraging fewer recommended follow-up visits, while simultaneously encouraging those who feel they need assistance to seek medical attention. Additional research is, however, needed to determine whether any revisits should be recommended in the absence of sign and symptoms.
Global Programme on AIDS. HIV sentinel surveillance. Zambia. Programme mondial de lutte contre le SIDA. Surveillance du VIH par sentinelles. Zambie.
Weekly Epidemiological Record / Releve Epidemiologique Hebdomadaire. 1992 Jul 24; 67(30):221-4.A plan of action for implementing sentinel surveillance of serological markers of human immunodeficiency virus (HIV) infections was drafted by the Zambia National AIDS Program (NAP) in 1989. The objective of HIV sentinel surveillance was the monitoring of patterns in HIV infections in different parts of Zambia for district HIV/AIDS prevention and control activities. 3 population subgroups were selected for surveillance: 1) outpatients attending selected sexually transmitted disease (STD) clinics who were either tested for syphilis or had blood taken; 2) blood donors tested for HIV at selected blood donation centers, and 3) pregnant women attending selected antenatal clinics who were tested for syphilis. 10 sentinel sites in different areas of Zambia were selected: 3 antenatal clinics and 1 STD clinic in Lusaka; 1 antenatal clinic, 1 STD clinic, and 1 blood donation center each in Solwezi town and Mukinge District, North-Western Province. From each sentinel site, samples were transported to 2 laboratories for HIV testing by 1 Wellcozyme recombinant antigen ELISA test. A predetermined sample of 100-250 consecutively collected blood samples was obtained every 6 months. The results of the sentinel surveillance indicated the highest prevalence of HIV infection in large urban areas, where between 1:5 (20%) and 1:4 (25%) adults in the reproductive age group may now be HIV-infected. Such high levels of HIV infection will probably have serious socioeconomic effects for Zambia within the next 5-10 years. NAP recommendations based on these results include: a broader involvement of society in HIV/AIDS prevention and control; voluntary HIV testing of individuals for counseling and medical management; intensification of condom promotion among STD clinic attenders; and information, education, and communication strategies for HIV/AIDS prevention and control focusing on reducing the number of sexual partners.
Tropical Doctor. 1984 Jan; 14(1):34-40.A description of the Dominican Child Health Passport (CHP) and its clinic-based counterpart are presented. These are adaptions of the World Health Organization (WHO) growth chart. A prototype of the chart was introduced in June, 1980 for a pilot project in the town of Portsmouth. At 7 consequtive child welfare clinics all parents who received a CHP at an earlier visit were interviewed. Questions were asked about some aspects of clinic attendance, the use of and attitude towards the CHP; and understanding of it. The children ranged in age from 1-21 months with a mean of 7 months. 31 parents (61%) had visited the clinic 4 weeks ago (the usual period between visits) and the average was 5 weeks. Weighing was the reason that 49% of the mothers brought their children to the clinic. This could mean that there is already an awareness of the importance of weighing for monitoring child health. Of the 51 parents, only 1 had forgotten the CHP. 10 children possessing a CHP were taken to a doctor. 6 mothers took the CHP along, and on 5 occasions the doctor showed an interest. Opinions on various aspects of the CHP are given. The price--60 cents Eastern Caribbean Currency (=US $0.22) was considered acceptable. Almost all mothers liked to have the CHP at home. However, a substantial % did not like the idea of having child spacing methods entered on the card. 4 CHPs with different weight curves were shown to mothers, who were asked if they would worry about a child who showed the growth pattern indicated. Severe underweight with loss of weight was recognized by 51% of the interviewees. Obesity was not usually considered something to worry about; this is understandable in a place where undernourishment is common in infants. About 1/3 of the respondents recognized the danger if an infant was still in the normal range of weight-for-age but was losing weight.
Overview: 1975. Contraceptive services of the family planning programs of IPPF in the Western Hemisphere.
New York, International Planned Parenthood Federation, Western Hemsisphere Region, Medical Department, Nov. 1976. 28 pAdd to my documents.
Overview of the medical and clinical activities performed by the family planning associations of the Western Hemisphere Region.
N.Y., International Planned Parenthood Federation Western Hemisphere Region, 1973. 103 pAdd to my documents.
London, International Planned Parenthood Federation, Evaluation and Social Sciences Department, May 1976. (Research for Action No. 2) 13 pThe Botswana government, now an affiliate member of the International Planned Parenthood Federation (IPPF), and the IPPF have collaborated since 1969 in the stablishment of family planning services within the maternal and child health programs. Evaluation of the family planning aspects of this program conducted between April 1972 and October 1973 focused on 3specific research studies: 1) a description of the Family Welfare Educator cadre in Botswana, their workload, problems, and training; 2) an analysis of service statistics generated by the Maternal and Child Health Family Planning programs; and 3) a follow-up survey to trace family planning acceptors. By April 1972, 60 women had been trained as family welfare educators. A weekly reporting system was introduced as a means of establishing contact between the family welfare educators and the Office for Maternal and Child Health/Family Planning, learning about the problems workers encountered, and assessing their work. In studying the service statistics it was learned that over the 5 years of this study period 72% of the clients received oral contraceptives, 16% IUDs, and 2% injections on their 1st visit to the clinic. The ratio of oral contraceptives to IUD acceptors changed from .75:1 in 1968 to 28:1 in 1972. It was found that nearly 1/3 of the clients discontinued contraceptive use within 3 months and nearly 2/3 within a year. It was recommended that greater emphasis be placed on the IUD as a method of contraception. Regarding the follow-up survey, a 100% sample of new acceptors in the selected months was drawn from the records of Gaborone and Serowe clinics and data were abstracted from the individual client cards at each clinic. It was learned that 20% of the women interviewed discontinued contraception within 6 months and 34% within a year. These continuation rates were lower than those derived from service statistics. It was recommended that follow-up surveys be repeated at regular intervals in order to monitor the acceptability of the program to new acceptors and to ensure client feedback to improve the program.
New York, International Planned Parenthood Federation, Western Hemisphere Region, September 1975. 149 pThe primary focus in this 4th edition in the series of annual "overviews" of the contraceptive services in the Western Hemisphere Region of the International Planned Parenthood Federation is on clinical facilities, medical and paramedical services, and on the delivery of contraceptive methods by family planning programs. Family planning services link information on methods for spacing or limiting children to their availability, and they provide education on the advantages of contracepting. They seek to motivate acceptors to continue their chosen method. Counseling and information and education activities, although an integral component of family planning programs, are not included among the topics considered in the "Overview." In the Western Hemisphere Region, the most notable innovation has involved the community-based distribution of contraceptives (CBD), and for the 1st time, non-clinical distribution of contraceptives by associations in the region is a part of the "Overview." The Annual Reports submitted by IPPF affiliates and published and unpublished data from other programs are the primary sources of statistics for this report. Information for 1973 encompassed 29 associations related to IPPF and 4 other programs, and for 1974, 28 associations and 5 other programs could be covered. As for clinical input of family planning programs, the affiliates reported to the Regional Office of IPPF the number and types of clinics, weekly session hours, hours of medical and paramedical personnel. Data on the output of clinical activities of family planning programs for the calendar year were limited to 1st visits or new acceptors by methods, 1st revisits of the year or continuing (old) acceptors by method, number of revisits by old and new acceptors by method, demographic characteristics of new acceptors by method, and voluntary male and female sterilization performed or referred. Data on contraceptive services and clinical activities are summarized and presented in the form of tables.