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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.
Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health.
BJOG: An International Journal of Obstetrics and Gynaecology. 2014 Mar; 121 Suppl 1:76-88.OBJECTIVE: We aimed to determine the prevalence and risks of late fetal deaths (LFDs) and early neonatal deaths (ENDs) in women with medical and obstetric complications. DESIGN: Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS). SETTING: A total of 359 participating facilities in 29 countries. POPULATION: A total of 308 392 singleton deliveries. METHODS: We reported on perinatal indicators and determined risks of perinatal death in the presence of severe maternal complications (haemorrhagic, infectious, and hypertensive disorders, and other medical conditions). MAIN OUTCOME MEASURES: Fresh and macerated LFDs (defined as stillbirths >/= 1000 g and/or >/=28 weeks of gestation) and ENDs. RESULTS: The LFD rate was 17.7 per 1000 births; 64.8% were fresh stillbirths. The END rate was 8.4 per 1000 liveborns; 67.1% occurred by day 3 of life. Maternal complications were present in 22.9, 27.7, and 21.2% [corrected] of macerated LFDs, fresh LFDs, and ENDs, respectively. The risks of all three perinatal mortality outcomes were significantly increased with placental abruption, ruptured uterus, systemic infections/sepsis, pre-eclampsia, eclampsia, and severe anaemia. CONCLUSIONS: Preventing intrapartum-related perinatal deaths requires a comprehensive approach to quality intrapartum care, beyond the provision of caesarean section. Early identification and management of women with complications could improve maternal and perinatal outcomes. (c) 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.
Obstetrics and Gynecology. 2007 Nov; 110(5):1017-1018.Between the 1970s and 1990s, the World Health Organization promoted traditional birth attendant (TBA) training as one strategy to reduce maternal and neonatal mortality. To date, evidence in support of TBA training remains limited and conflicting. The objectives were to assess effects of TBA training on health behaviors and pregnancy outcomes. We searched the Trials Registers of the Cochrane Pregnancy and Childbirth Group and Cochrane Effective Practice and Organisation of Care Group (EPOC) (June 2006); electronic databases representing fields of education, social, and health sciences (inception to June 2006); the internet; and contacted experts. Published and unpublished randomized controlled trials (RCT), controlled before/after and interrupted time series studies comparing trained and untrained TBAs or women cared for/living in areas served by TBAs. Three authors independently assessed study quality and extracted data. Four studies, involving over 2,000 TBAs and nearly 27,000 women, are included. One cluster-randomized trial found significantly lower rates in the intervention group regarding stillbirths (adjusted odds ratio [OR] 0.69, 95% confidence interval [CI] 0.57-0.83, P less than .001), perinatal death rate (adjusted OR 0.70, 95% CI 0.59-0.83, P less than .001) and neonatal death rate (adjusted OR 0.71, 95% CI 0.61-0.82, P less than .001). Maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45-1.22, P=.24) while referral rates were significantly higher (adjusted OR 1.50, 95% CI 1.18-1.90, P less than .001). A controlled before/after study among women who were referred to a health service found perinatal deaths decreased in both intervention and control groups, with no significant difference between groups (OR 1.02, 95% CI 0.59-1.76, P=.95). Similarly, the mean number of monthly referrals did not differ between groups (P=.321). One RCT found a significant difference in advice about introduction of complementary foods (OR 2.07, 95% CI 1.10-3.90, P=.02) but no significant difference for immediate feeding of colostrum (OR 1.37, 95% CI 0.62-3.03, P=.44). Another RCT found no significant differences in frequency of postpartum hemorrhage (OR 0.94, 95% CI 0.76-1.17, P=.60) among women cared for by trained versus TBAs. The potential of TBA training to reduce peri-neonatal mortality is promising when combined with improved health services. However, the number of studies meeting the inclusion criteria is insufficient to provide the evidence base needed to establish training effectiveness. (author's)
In: Disease control priorities in developing countries. 2nd ed., edited by Dean T. Jamison, Joel G. Breman, Anthony R. Measham, George Alleyne, Mariam Claeson et al. Washington, D.C., World Bank, 2006. 499-529.The Millennium Declaration includes two goals directly relevant to maternal and perinatal conditions: reducing child mortality and improving maternal health. The fact that two out of the eight Millennium Development Goals (MDGs) are exclusively targeted at mothers and children is testament to the significant proportion of the global burden of disease they suffer and to the huge inequities within and between countries in the magnitude of their burden. Achieving these goals is inextricably linked at the biological, intervention, and service delivery levels. Maternal and child health services have long been seen as inseparable partners, although over the past 20 years the relative emphasis within each, particularly at a policy level, has varied. The launch of the Safe Motherhood Initiative in the late 1980s, for example, brought heightened attention to maternal mortality, whereas the International Conference on Population and Development (ICPD) broadened the focus to reproductive health and, more recently, to reproductive rights. Those shifts can be linked with international programmatic responses and terminology-with the preventive emphasis of, for instance, prenatal care being lowered as a priority relative to the treatment focus of emergency obstetric care. For the child, integrated management of childhood illnesses has brought renewed emphasis to maintaining a balance between preventive and curative care. The particular needs of the newborn, however, have only started to receive significant attention in the past three or four years. (excerpt)
Food and Nutrition Bulletin. 2003; 24 Suppl 4:S99-S103.Iron deficiency is considered to be one of most prevalent forms of malnutrition, yet there has been a lack of consensus about the nature and magnitude of the health consequences of iron deficiency in populations. This paper presents new estimates of the public health importance of iron-deficiency anemia (IDA), which were made as part of the Global Burden of Disease (GBD) 2000 project. Iron deficiency is considered to contribute to death and disability as a risk factor for maternal and perinatal mortality, and also through its direct contributions to cognitive impairment, decreased work productivity, and death from severe anemia. Based on meta-analysis of observational studies, mortality risk estimates for maternal and perinatal mortality are calculated as the decreased risk in mortality for each 1 g/dl increase in mean pregnancy hemoglobin concentration. On average, globally, 50% of the anemia is assumed to be attributable to iron deficiency. Globally, iron deficiency ranks number 9 among 26 risk factors included in the GBD 2000, and accounts for 841,000 deaths and 35,057,000 disability-adjusted life years lost. Africa and parts of Asia bear 71% of the global mortality burden and 65% of the disability-adjusted life years lost, whereas North America bears 1.4% of the global burden. There is an urgent need to develop effective and sustainable interventions to control iron-deficiency anemia. This will likely not be achieved without substantial involvement of the private sector. (author's)
Brazzaville, Congo, WHO, Regional Office for Africa, 2002. 4 p.Newborns hold every country's promise for the future, yet they are Africa's forgotten children. Many times newborn deaths even go unrecorded, unknown to all but the grieving families. In the African region, almost half of all deaths in the first year of life take place in the first month, most of them during the first week. For every baby who dies within the first four weeks (the neonatal period),another one is stillborn. The newborn death rate is a sensitive indicator of the quality of health services. Even though the unacceptably high neonatal mortality rate has changed little over the past 30 years, no major, global programme focuses on newborn health. This indicates neglect of the most vulnerable members of society and of their right to quality care and good health. (excerpt)