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Updated WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage. Highlights and key messages from the World Health Organization's 2017 Global Recommendation.
Geneva, Switzerland, WHO, 2017 Oct. 5 p. (WHO/RHR/17.21)This summary brief highlights key messages from the updated World Health Organization’s recommendation on Tranexamic acid (TXA) for the treatment of postpartum haemorrhage (PPH), including policy and program implications for translating the TXA recommendation into action at the country level. In 2012, WHO published recommendations for the prevention and treatment of postpartum haemorrhage, including a recommendation on the use of tranexamic acid (TXA) for treatment of PPH. The 2017 updated WHO Recommendation on TXA is based on new evidence on use of TXA for treatment of PPH. Key messages include: 1) The World Health Organization (WHO) recommends early use of intravenous tranexamic acid (TXA) within 3 hours of birth in addition to standard care for women with clinically diagnosed postpartum haemorrhage (PPH) following vaginal birth or caesarean section; 2) Administration of TXA should be considered as part of the standard PPH treatment package and be administered as soon as possible after onset of bleeding and within 3 hours of birth. TXA for PPH treatment should not be initiated more than 3 hours after birth; 3) TXA should be used in all cases of PPH, regardless of whether the bleeding is due to genital tract trauma or other causes; 4) TXA should be administered at a fixed dose of 1 g in 10 mL (100 mg/mL) IV at 1 mL per minute (i.e., administered over 10 minutes), with a second dose of 1 g IV if bleeding continues after 30 minutes; and 5) TXA should be administered via an IV route only for treatment of PPH. Research on other routes of TXA administration is a priority.This summary brief is intended for policy-makers, programme managers, educators and providers.
Geneva, Switzerland, WHO, 2013 Oct.  p.The postnatal period is a critical phase in the lives of mothers and newborn babies. Most maternal and infant deaths occur during this time. Yet, this is the most neglected period for the provision of quality care. WHO guidelines on postnatal care have been recently updated based on all available evidence. The guidelines focus on postnatal care of mothers and newborns in resource-limited settings in low- and middle-income countries. The guidelines address timing, number and place of postnatal contacts, and content of postnatal care for all mothers and babies during the six weeks after birth. The primary audience for these guidelines is health professionals who are responsible for providing postnatal care to women and newborns, primarily in areas where resources are limited. The guidelines are also expected to be used by policy-makers and managers of maternal and child health programmes, health facilities, and teaching institutions to set up and maintain maternity and newborn care services. The information in these guidelines is expected to be included in job aids and tools for both pre- and in-service training of health professionals to improve their knowledge, skills and performance in postnatal care. These recommendations will be regularly updated as more evidence is collated and analysed on a continuous basis, with major reviews and updates at least every five years. The next major update will be considered in 2018 under the oversight of the WHO Guidelines Review Committee.
Postnatal care for mothers and newborns: Highlights from the World Health Organization 2013 guidelines.
[Geneva, Switzerland], World Health Organization [WHO], 2015 Apr.  p. (WHO/RHR/15.05; USAID Leader with Associates Cooperative Agreement No. GHS-A-00-08-00002-00; USAID Cooperative Agreement No. AID-OAA-A-14-00028)This evidence brief provides highlights and key messages from World Health Organization’s 2013 Guidelines on Postnatal Care for Mothers and Newborns. These updated guidelines address the timing and content of postnatal care for mothers with a special focus on resource-limited settings in low- and middle-income countries. This brief is intended for policy-makers, programme managers, educators and providers who care for women and newborns after birth.
Guideline: Delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes.
Geneva, Switzerland, WHO, 2014.  p.This guideline is a derivative product from existing World Health Organization (WHO) recommendations on umbilical cord clamping for improving maternal and infant outcomes. The optimal timing of umbilical cord clamping has been debated in the scientific literature for at least a century, and the timing of cord clamping continues to vary according to clinical policy and practice. “Early” cord clamping is generally carried out in the first 60 seconds after birth (most commonly in the first 15-30 seconds), whereas “delayed” (also referred to as “late”) cord clamping is generally carried out more than 1 min after the birth or when the umbilical cord pulsation has ceased. For the mother, delayed cord clamping is one of the actions included in a package for reduction of the risk of postpartum haemorrhage. Member States have requested guidance from WHO on the effects of delayed cord clamping for improving maternal and infant nutrition and health, as a public health strategy in support of their efforts to achieve the Millennium Development Goals, in particular, reduction of child mortality (MDG 4) and improvement of maternal health (MDG 5), as well as the global targets set in the Comprehensive implementation plan on maternal, infant and young child nutrition. The guideline is intended for a wide audience, including policy-makers; their expert advisers; technical and programme staff at organizations involved in the design, implementation and scaling-up of nutrition actions for public health; and health staff providing care to mothers and their infants. (Excerpt)
Geneva, Switzerland, WHO, 2015.  p. (WHO/RHR/15.07)This executive summary contains all the new recommendations that will be incorporated into the fifth edition of the Medical eligibility criteria for contraceptive use. In addition to the recommendations themselves, the summary provides an introduction to the guideline, a description of the methods used to develop the recommendations for this fifth edition, and a summary of changes (from the fourth edition to the fifth edition of the MEC). It is anticipated that the Medical eligibility criteria for contraceptive use, fifth edition will be available online by 1 July 2015. In the interim, the fourth edition of the guideline, along with this summary of new recommendations provides the complete set of WHO recommendations on medical eligibility criteria for contraceptive use.
Journal of Midwifery and Women's Health. 2011 Nov; 56(6):598-607.In the late 1990s, the World Health Organization (WHO) created the Medical Eligibility Criteria for Contraceptive Use (MEC), which provide evidence-based recommendations for safe and effective contraception in women with medical problems. The WHO MEC incorporate the best available evidence, are periodically updated, and are designed to be modified for specific populations. The US Centers for Disease Control and Prevention published US MEC in 2010. Changes to WHO guidelines for use in the US population include the following areas: breastfeeding, intrauterine device use, valvular heart disease, ovarian cancer, uterine fibroids, and venous thromboembolism. Medical conditions not covered by WHO recommendations but added to the US MEC include contraceptive guidance for women with inflammatory bowel disease, history of bariatric surgery, rheumatoid arthritis, endometrial hyperplasia, history of peripartum cardiomyopathy, and history of solid organ transplant. This article reviews the changes and additions to WHO MEC found in the US MEC. (c) 2011 by the American College of Nurse-Midwives.
[Geneva, Switzerland], WHO, 2011.  p.As part of its "Making Pregnancy Safer" series, the World Health Organization answers the following questions about skilled birth attendants: Who is a skilled birth attendant? In how many births do skilled attendants assist? How do skilled attendants care for mothers and babies? How does skilled birth care impact on maternal mortality? How can the coverage be increased? What does WHO do to increase skilled care at birth?
Postpartum Family Planning: Sharing Experiences, Lessons Learned and Tools for Programming -- Meeting report, 12 May 2009, Washington, D.C.
Baltimore, Maryland, Jhpiego, ACCESS, Family Planning Initiative [ACCESS-FP], 2009.  p.On May 12, 2009, more than 76 experts and leaders in reproductive health (RH) and maternal, neonatal and child health (MNCH) from more than 22 global health organizations and programs convened in Washington, D.C., for the “Postpartum Family Planning: Sharing Experiences, Lessons Learned and Tools for Programming” meeting. The meeting had three objectives: 1. Present and discuss experiences and lessons learned in implementing PPFP in a variety of settings; 2. Share tools and other resources to support PPFP programming; and 3. Discuss progress, continuing priorities for research and advancing MNCH / FP integration. (Excerpts)
Low sensitivity of total lymphocyte count as a surrogate marker to identify antepartum and postpartum Indian women who require antiretroviral therapy.
Journal of Acquired Immune Deficiency Syndromes. 2007 Nov; 46(3):338-342.Some studies support the use of total lymphocyte count (TLC) as a surrogate marker for CD4 cell count to guide antiretroviral therapy (ART) initiation. However, most of these studies have focused on nonpregnant adults. In light of expanding ART access through prevention of mother-to-child transmission (PMTCT)-plus programs in resource-limited settings, we assessed the sensitivity, specificity, and positive predictive value (PPV) of TLC for predicting low CD4 counts in antepartum and postpartum women in Pune, India. CD4, TLC, and hemoglobin were measured at third trimester, delivery, and 6, 9, and 12 months postpartum (PP) in a cohort of 779 HIV-infected women. Optimal TLC cutoff for predicting CD4 < 200 cells/mm3 was determined via logistic regression where sensitivity, specificity, PPV, and an area under the receiver operating characteristic (ROC) curve were calculated. Among the 779 women enrolled, 16% had WHO clinical stage 2 or higher and 7.9% had CD4 < 200 cells/mm3. Using 2689 TLC-CD4 pairs,the sensitivity, specificity, and PPV of TLC < 1200 cells/mm3 for predicting CD4 < 200 cells/mm3 was 59%, 94%, and 47%, respectively. The sensitivity of TLC < 1200 cells/mm3 cutoff ranged between 57% and 62% for time points evaluated. Addition of hemoglobin < 12 g/dL or < 11 g/dL increased the sensitivity of TLC to 74% to 92% for predicting CD4 < 200 cells/mm3 but decreased the specificity to 33% to 69% compared to TLC alone. A combination of TLC, hemoglobin, and WHO clinical staging had the highest sensitivity but lowest specificity compared to other possible combinations or use of TLC alone. The sensitivity and specificity of TLC < 1200 cells/mm3 to predict a CD4 < 350 cells/mm3 was 31% and 99%, respectively. Our data suggest that antepartum and PP women with TLC < 1200 cells/mm3 are likely to have CD4 < 200 cells/mm3. However, the sensitivity of this TLC cutoff was low. Between 45% and 64% of antepartum and PP women requiring initiation of ART may not be identified by using TLC alone as a surrogate markerfor CD4 < 200 cells/mm3. The WHO-recommended TLC cutoff of < 1200 cells/mm3 is not optimal for identifying antepartum and PP Indian women who require ART. (author's)
Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. [Tasas de cesáreas y resultados de embarazos: la encuesta mundial de la OMS del año 2005 sobre salud materna y perinatal en América Latina]
Lancet. 2006 Jun 3; 367(9525):1819-1829.Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics. For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions. We also obtained institutional-level data. We obtained data for 97 095 of 106 546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24--43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43--57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity. Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%. High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm. (author's)
In: WHO updates medical eligibility criteria for contraceptives, by Ward Rinehart. Baltimore, Maryland, Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs, Information and Knowledge for Optimal Health Project [INFO], 2004 Aug. 5. (INFO Reports No. 1; USAID Grant No. GPH-A-00-02-00003-00)Considering depressive disorders for the first time, the October 2003 MEC meeting concluded that there is no need for restriction on use of hormonal contraceptives for women with depression. A variety of studies have found no increase in symptoms among depressed women using combined or progestin-only oral contraceptives, DMPA injectable, or Norplant implants. A single study reported that taking fluoxetine (Prozac) for depression did not reduce the effectiveness of combined or progestin- only oral contraceptives. Conclusions cannot be reached concerning postpartum depression or bipolar disorder because current evidence is inadequate. (excerpt)
Acta Obstetricia et Gynecologica Scandinavica. 2003 Nov; 82(11):1063-1064.In these days of evidence-based medicine, whatever is done to provide evidence in favor or against a procedure, protocol, program, test or intervention is always welcomed. It is in this light that the new World Health Organization (WHO) antenatal care model, now being propagated for general implementation, will be assessed. The focus of the WHO antenatal model was the developing countries because it was rightly assumed that the routinely recommended antenatal care program is often poorly implemented and clinical visits can be irregular, with long waiting times and poor feedback to the women. A multicenter, randomized, control trial was therefore conducted to compare the old, standard "western" model of antenatal care with the new WHO model, which limits the number of visits to the clinic and restricts tests and clinical procedures. But this all-important study did not consider it appropriate to include at least one African country, with all the peculiarities of sub- Saharan Africa. Even then, out of the four chosen countries, Saudi Arabia, for instance, cannot be said to be a classic example of a developing country. The design of the study was therefore suspect from the outset! A closer look at the trial itself revealed more defects and debatable issues. For instance, the primary maternal outcome monitored was a maternal morbidity index, partly defined by eclampsia occurring within 24 h of delivery and severe postpartum anemia (hemoglobin <90 g/L). The issue of excluding eclamptics whose fits occur after 24 h of delivery might not be as controversial as labeling patients with hemoglobin of <90 g/L with severe anemia. Certainly there are many elegant studies that do not support that definition of severity, at least for African mothers. (excerpt)