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Perinatal outcomes in twin pregnancies complicated by maternal morbidity: evidence from the WHO Multicountry Survey on Maternal and Newborn Health.
BMC Pregnancy and Childbirth. 2018 Nov 20; 18(1):449.BACKGROUND: Twin pregnancy was associated with significantly higher rates of adverse neonatal and perinatal outcomes, especially for the second twin. In addition, the maternal complications (potentially life-threatening conditions-PLTC, maternal near miss-MNM, and maternal mortality-MM) are directly related to twin pregnancy and independently associated with adverse perinatal outcome. The objective of the preset study is to evaluate perinatal outcomes associated with twin pregnancies, stratified by severe maternal morbidity and order of birth. METHODS: Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), a cross-sectional study implemented in 29 countries. Data from 8568 twin deliveries were compared with 308,127 singleton deliveries. The occurrence of adverse perinatal outcomes and maternal complications were assessed. Factors independently associated with adverse perinatal outcomes were reported with adjusted PR (Prevalence Ratio) and 95%CI. RESULTS: The occurrence of severe maternal morbidity and maternal death was significantly higher among twin compared to singleton pregnancies in all regions. Twin deliveries were associated with higher rates of preterm delivery (37.1%), Apgar scores less than 7 at 5th minute (7.8 and 10.1% respectively for first and second twins), low birth weight (53.2% for the first and 61.1% for the second twin), stillbirth (3.6% for the first and 5.7% for the second twin), early neonatal death (3.5% for the first and 5.2% for the second twin), admission to NICU (23.6% for the first and 29.3% for the second twin) and any adverse perinatal outcomes (67% for the first twin and 72.3% for the second). Outcomes were consistently worse for the second twin across all outcomes. Poisson multiple regression analysis identified several factors independently associated with an adverse perinatal outcome, including both maternal complications and twin pregnancy. CONCLUSION: Twin pregnancy is significantly associated with severe maternal morbidity and with worse perinatal outcomes, especially for the second twin.
Adaptation of the WHO maternal near miss tool for use in sub-Saharan Africa: an International Delphi study.
BMC Pregnancy and Childbirth. 2017 Dec 29; 17(1):445.BACKGROUND: Assessments of maternal near miss (MNM) are increasingly used in addition to those of maternal mortality measures. The World Health Organization (WHO) has introduced an MNM tool in 2009, but this tool was previously found to be of limited applicability in several low-resource settings. The aim of this study was to identify adaptations to enhance applicability of the WHO MNM tool in sub-Saharan Africa. METHODS: Using a Delphi consensus methodology, existing MNM tools were rated for applicability in sub-Saharan Africa over a series of three rounds. Maternal health experts from sub-Saharan Africa or with considerable knowledge of the context first rated importance of WHO MNM parameters using Likert scales, and were asked to suggest additional parameters. This was followed by two confirmation rounds. Parameters accepted by at least 70% of the panel members were accepted for use in the region. RESULTS: Of 58 experts who participated from study onset, 47 (81%) completed all three rounds. Out of the 25 WHO MNM parameters, all 11 clinical, four out of eight laboratory, and four out of six management-based parameters were accepted, while six parameters (PaO2/FiO2 < 200 mmHg, bilirubin >100 mumol/l or >6.0 mg/dl, pH <7.1, lactate >5 mumol/l, dialysis for acute renal failure and use of continuous vasoactive drugs) were deemed to not be applicable. An additional eight parameters (uterine rupture, sepsis/severe systemic infection, eclampsia, laparotomy other than caesarean section, pulmonary edema, severe malaria, severe complications of abortions and severe pre-eclampsia with ICU admission) were suggested for inclusion into an adapted sub-Saharan African MNM tool. CONCLUSIONS: All WHO clinical criteria were accepted for use in the region. Only few of the laboratory- and management based were rated applicable. This study brought forward important suggestions for adaptations in the WHO MNM criteria to enhance its applicability in sub-Saharan Africa and possibly other low-resource settings.
Influenza epidemiology and immunization during pregnancy: Final report of a World Health Organization working group.
Vaccine. 2017 Oct 13; 35(43):5738-5750.From 2014 to 2017, the World Health Organization convened a working group to evaluate influenza disease burden and vaccine efficacy to inform estimates of maternal influenza immunization program impact. The group evaluated existing systematic reviews and relevant primary studies, and conducted four new systematic reviews. There was strong evidence that maternal influenza immunization prevented influenza illness in pregnant women and their infants, although data on severe illness prevention were lacking. The limited number of studies reporting influenza incidence in pregnant women and infants under six months had highly variable estimates and underrepresented low- and middle-income countries. The evidence that maternal influenza immunization reduces the risk of adverse birth outcomes was conflicting, and many observational studies were subject to substantial bias. The lack of scientific clarity regarding disease burden or magnitude of vaccine efficacy against severe illness poses challenges for robust estimation of the potential impact of maternal influenza immunization programs. Copyright (c) 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.
Option B+ for prevention of vertical HIV transmission has no influence on adverse birth outcomes in a cross-sectional cohort in Western Uganda.
BMC Pregnancy and Childbirth. 2017 Mar 7; 17(82):1-12.Background While most Sub-Saharan African countries are now implementing the WHO-recommended Option B+ protocol for prevention of vertical HIV transmission, there is a lack of knowledge regarding the influence of Option B+ exposure on adverse birth outcomes (ABOs). Against this background, we assessed ABOs among delivering women in Western Uganda. Methods A cross-sectional, observational study was performed within a cohort of 412 mother-newborn-pairs in Virika Hospital, Fort Portal in 2013. The occurrence of stillbirth, pre-term delivery, and small size for gestational age (SGA) was analyzed, looking for influencing factors related to HIV-status, antiretroviral drug exposure and duration, and other sociodemographic and clinical parameters. Results Among 302 HIV-negative and 110 HIV-positive women, ABOs occurred in 40.5%, with stillbirth in 6.3%, pre-term delivery in 28.6%, and SGA in 12.2% of deliveries. For Option B+ intake (n = 59), no significant association was found with stillbirth (OR 0.48, p = 0.55), pre-term delivery (OR 0.97, p = 0.92) and SGA (OR 1.5, p = 0.3) compared to seronegative women. Women enrolled on antiretroviral therapy (ART) before conception (n = 38) had no different risk for ABOs than women on Option B+ or HIV-negative women. Identified risk factors for stillbirth included lack of formal education, poor socio-economic status, long travel distance, hypertension and anemia. Pre-term delivery risk was increased with poor socio-economic status, primiparity, Malaria and anemia. The occurrence of SGA was influenced by older age and Malaria. Conclusion In our study, women on Option B+ showed no difference in ABOs compared to HIV-negative women and to women on ART. We identified several non-HIV/ART-related influencing factors, suggesting an urgent need for improving early risk assessment mechanisms in antenatal care through better screening and triage systems. Our results are encouraging with regard to continued universal scale-up of Option B+ and ART programs.
Pre-conception counselling for key cardiovascular conditions in Africa: optimising pregnancy outcomes.
Cardiovascular Journal of Africa. 2016 Mar-Apr; 27(2):79-83.The World Health Organisation (WHO) supports pre-conception care (PCC) towards improving health and pregnancy outcomes. PPC entails a continuum of promotive, preventative and curative health and social interventions. PPC identifies current and potential medical problems of women of childbearing age towards strategising optimal pregnancy outcomes, whereas antenatal care constitutes the care provided during pregnancy. Optimised PPC and antenatal care would improve civil society and maternal, child and public health. Multiple factors bar most African women from receiving antenatal care. Additionally, PPC is rarely available as a standard of care in many African settings, despite the high maternal mortality rate throughout Africa. African women and healthcare facilitators must cooperate to strategise cost-effective and cost-efficient PPC. This should streamline their limited resources within their socio-cultural preferences, towards short- and long-term improvement of pregnancy outcomes. This review discusses the relevance of and need for PPC in resource-challenged African settings, and emphasises preventative and curative health interventions for congenital and acquired heart disease. We also consider two additional conditions, HIV/AIDS and hypertension, as these are two of the most important co-morbidities encountered in Africa, with significant burden of disease. Finally we advocate strongly for PPC to be considered as a key intervention for reducing maternal mortality rates on the African continent.
Indirect causes of severe adverse maternal outcomes: a secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health.
BJOG: An International Journal of Obstetrics and Gynaecology. 2014 Mar; 121 Suppl 1:32-9.OBJECTIVE: To assess the proportion of severe maternal outcomes resulting from indirect causes, and to determine pregnancy outcomes of women with indirect causes. DESIGN: Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health. SETTING: A total of 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East. SAMPLE: A total of 314 623 pregnant women admitted to the participating facilities. METHODS: We identified the percentage of women with severe maternal outcomes arising from indirect causes. We evaluated the risk of severe maternal and perinatal outcomes in women with, versus without, underlying indirect causes, using adjusted odds ratios and 95% confidence intervals, by a multilevel, multivariate logistic regression model, accounting for clustering effects within countries and health facilities. MAIN OUTCOME MEASURES: Severe maternal outcomes and preterm birth, fetal mortality, early neonatal mortality, perinatal mortality, low birthweight, and neonatal intensive care unit admission. RESULTS: Amongst 314 623 included women, 2822 were reported to suffer from severe maternal outcomes, out of which 20.9% (589/2822; 95% CI 20.1-21.6%) were associated with indirect causes. The most common indirect cause was anaemia (50%). Women with underlying indirect causes showed significantly higher risk of obstetric complications (adjusted odds ratio, aOR, 7.0; 95% CI 6.6-7.4), severe maternal outcomes (aOR 27.9; 95% CI 24.7-31.6), and perinatal mortality (aOR 3.8; 95% CI 3.5-4.1). CONCLUSIONS: Indirect causes were responsible for about one-fifth of severe maternal outcomes. Women with underlying indirect causes had significantly increased risks of severe 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.
Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study.
BJOG: An International Journal of Obstetrics and Gynaecology. 2014 Mar; 121 Suppl 1:40-8.OBJECTIVE: To investigate the risk of adverse pregnancy outcomes among adolescents in 29 countries. DESIGN: Secondary analysis using facility-based cross-sectional data of the World Health Organization Multicountry Survey on Maternal and Newborn Health. SETTING: Twenty-nine countries in Africa, Latin America, Asia and the Middle East. POPULATION: Women admitted for delivery in 359 health facilities during 2-4 months between 2010 and 2011. METHODS: Multilevel logistic regression models were used to estimate the association between young maternal age and adverse pregnancy outcomes. MAIN OUTCOME MEASURES: Risk of adverse pregnancy outcomes among adolescent mothers. RESULTS: A total of 124 446 mothers aged =24 years and their infants were analysed. Compared with mothers aged 20-24 years, adolescent mothers aged 10-19 years had higher risks of eclampsia, puerperal endometritis, systemic infections, low birthweight, preterm delivery and severe neonatal conditions. The increased risk of intra-hospital early neonatal death among infants born to adolescent mothers was reduced and statistically insignificant after adjustment for gestational age and birthweight, in addition to maternal characteristics, mode of delivery and congenital malformation. The coverage of prophylactic uterotonics, prophylactic antibiotics for caesarean section and antenatal corticosteroids for preterm delivery at 26-34 weeks was significantly lower among adolescent mothers. CONCLUSIONS: Adolescent pregnancy was associated with higher risks of adverse pregnancy outcomes. Pregnancy prevention strategies and the improvement of healthcare interventions are crucial to reduce adverse pregnancy outcomes among adolescent women in low- and middle-income countries. (c) 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.
Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study.
Lancet. 2013 May 18; 381(9879):1747-1755.Background: We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. Methods: In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; i.e., maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (e.g., the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (i.e., the ability to produce a positive effect on health outcomes) through standardised mortality ratios. Results: From May 1, 2010, to Dec 31, 2011, we included 314 623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). Interpretation: High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy.
The scorecard: Moniitoring and evaluating the implementation of the World Bank’s Reproductive Health Action Plan 2010–2015.
London, United Kingdom, IPPF, 2011 Jul.  p.This scorecard is an analysis of the World Bank's Reproductive Health Action Plan. Approved in 2010, the Action Plan marks the Bank's renewed commitment to sexual and reproductive health. Building on recommendations of an evaluation of the Bank and consultation with civil society, it sets out the Bank's approach to increase its effectiveness in promoting and supporting national policies and strategies for reproductive health, and to support improved reproductive health outcomes at national level. One year after its approval, it is time to take stock of the Plan; to assess implementation globally and nationally; to celebrate progress; and to identify where increased focus is needed to ensure that the Plan is reflected in Bank policy and lending patterns. This scorecard includes an analysis of the Reproductive Health Action Plan and its Results Framework. It reviews progress to date and makes recommendations for changes to the indicators. It also includes three country scorecards -- for Burkina Faso, Mali and Ethiopia -- which chart progress at country level in three of the 57 focal countries. (Excerpts)
International Journal of Gynaecology and Obstetrics. 2009 Dec; 107(3):191-7.OBJECTIVE: To assess the association between cesarean delivery rates and pregnancy outcomes in African health facilities. METHODS: Data were obtained from all births over 2-3 months in 131 facilities. Outcomes included maternal deaths, severe maternal morbidity, fresh stillbirths, and neonatal deaths and morbidity. RESULTS: Median cesarean delivery rate was 8.8% among 83439 births. Cesarean deliveries were performed in only 95 (73%) facilities. Facility-specific cesarean delivery rates were influenced by previous cesarean, pre-eclampsia, induced labor, referral status, and higher health facility classification scores. Pre-eclampsia increased the risks of maternal death, fresh stillbirths, and severe neonatal morbidity. Adjusted emergency cesarean delivery rate was associated with more fresh stillbirths, neonatal deaths, and severe neonatal morbidity--probably related to prolonged labor, asphyxia, and sepsis. Adjusted elective cesarean delivery rate was associated with fewer perinatal deaths. CONCLUSION: Use of cesarean delivery is limited in the African health facilities surveyed. Emergency cesareans, when performed, are often too late to reduce perinatal deaths.
Africa Renewal. 2008 Jan; 21(4):8-11.Pumwani Maternity Hospital, in Nairobi, Kenya, is the largest maternal health centre in East and Central Africa. Located close to Mathare and Korogocho, two of Nairobi's biggest slums, the hospital helps some 27,000 women give birth each year. Most are poor and young, between the ages of 14 and 18. The government-run hospital struggles to provide even the most basic services, since it lacks sufficient resources, equipment and staff. "We told patients to buy their own things because of the shortage of supplies," explains Evelyn Mutio, the former head of the hospital's nursing staff. "We told patients to come with gloves, to buy their own syringes, needles, cotton wool and maternity pads." The Pumwani Maternity Hospital exemplifies the state of the health infrastructure in Africa. According to the World Health Organization (WHO), high service costs, lack of trained staff and supplies, poor transport and patients' insufficient knowledge mean that 60 per cent of mothers in sub-Saharan Africa do not have a health worker present during childbirth. That heightens the risks of complications, contributing to greater maternal and child death and disability. (excerpt)
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)
Nursing for Women's Health. 2007 Oct-Nov; 11(5):468-473.The United Nations (UN) adopted a set of Millennium Development Goals (MDGs), which are aimed at obliterating some of the worst health and social welfare inequities in the world. Significantly, reducing childhood mortality is one of the most important goals, making neonatal nursing care one of today's most important global health policy issues. Determining the adequate numbers of neonatal nurses required and ascertaining the most appropriate training and education levels are central to the international health care agenda. Over the past decade, neonatal nurses from around the globe have expressed an interest in forming an international council of neonatal nurses. The impetus for wanting this group is the need for access to curriculum, research, continuing education, consulting experts and patient information. Globally, neonatal nurses recognize the need for continuous education and training as well as access to research in a field with an ever-changing and growing knowledge base. The demand is fora group devoted to improving the care and lives of infants, most especially neonates. Focus on neonates is essential because approximately 40 percent of the mortality for children under the age of 5 years occurs in the first 28 days of life. (excerpt)
Obstetric fistula: Guiding principles for clinical management and programme development, a new WHO guideline.
International Journal of Gynecology and Obstetrics. 2007 Nov; 99 Suppl 1:S117-S121.It is estimated that more than 2 million women are living with obstetric fistulas (OFs) worldwide, particularly in Africa and Asia, and yet this severe morbidity remains hidden. As a contribution to the global Campaign to End Fistula, the World Health Organization (WHO) published Obstetric fistula: Guiding principles for clinical management and programme development, a manual intended as a practical working document. Its 3 main objectives are to draw attention to the urgency of the OF issue and serve as an advocacy document for prompt action; provide policy makers and health professionals with brief, factual information and principles that will guide them at the national and regional levels as they develop strategies and programs to prevent and treat OFs; and assist health care professionals as they acquire better skills and develop more effective services to care for women treated for fistula repair. (author's)
Geneva, Switzerland, World Health Organization [WHO], 2006. 37 p.Recommendations for birth spacing made by international organizations are based on information that was available several years ago. While publications by the World Health Organization (WHO) and other international organizations recommend waiting at least 2-3 years between pregnancies to reduce infant and child mortality, and also to benefit maternal health, recent studies supported by the United States Agency for International Development (USAID) have suggested that longer birth spacing, 3-5 years, might be more advantageous. Country and regional programmes have requested that WHO clarify the significance of the USAID-supported studies. With support from USAID, WHO undertook a review of the evidence. From 13 to 15 June 2005, 37 international experts, including the authors of the background papers and WHO and United Nations Children's Fund (UNICEF) staff , participated in a WHO technical consultation held at WHO Headquarters in Geneva. The objective of the meeting was to review evidence on the relationship between different birth-spacing intervals and maternal, infant and child health outcomes and to provide advice about a recommended interval. Six background papers were considered, along with one supplementary paper. Prior to the meeting, the six main papers were sent to experts for review. Thirty reviews were received: 10 from staff in international organizations and 20 from experts from 13 countries. The reviews were compiled and circulated to all meeting participants. At the meeting, the authors of the background papers presented their work, and selected discussants presented the consolidated set of comments, including their own observations. Together, the draft papers and the various commentaries formed the basis for the discussions of the evidence and for the recommendations made by the group at the meeting for spacing after a live birth and after an abortion. (excerpt)
International Journal of Gynecology and Obstetrics. 2007 Feb; 96(2):147-150.The objective was to compare two World Health Organization (WHO) partographs -- a composite partograph including latent phase with a simplified one without the latent phase. Comparison of the two partographs in a crossover trial. Eighteen physicians participated in this trial. One or the other partograph was used in 658 parturients. The mean (S.D.) user-friendliness score was lower for the composite partograph (6.2 (0.9) vs. 8.6 (1.0); P = 0.002). Most participants (84%) experienced difficulty "sometimes" with the composite partograph, but no participant reported difficulty with the simplified partograph. While most maternal and perinatal outcomes were similar, labor values crossed the action line significantly more often when the composite partograph was used, and the women were more likely to undergo cesarean deliveries. The simplified WHO partograph was more user-friendly, was more to be completed than the composite partograph, and was associated with better labor outcomes. (author's)
BMJ. British Medical Journal. 2006 Jul 15; 333(7559):106-107.In this week's BMJ, Elmusharaf and colleagues present a study of the agreement between self reports of female genital mutilation and the findings of clinical examination in a cohort of girls and another of women. They report that girls and women were inaccurate in describing what had been done to them, and that the actual mutilations did not readily fit into the World Health Organization's classification system. These findings have implications for research and, more broadly, for tackling the problem of female genital mutilation worldwide. They suggest that we need to re-examine our current conceptualisation of female genital mutilation with a view to defining a valid and reliable definition and classification system. (excerpt)
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)
Lancet. 2006 Jun 3; 367(9525):1799-1800.In today's Lancet, the WHO study group report a multicentre prospective study of the obstetric outcome in women who have had genital mutilation. Their study strengthens the evidence base about complications of such mutilation. For a subject with many important confounding factors, we congratulate the researchers for the study design and tenacity in execution. The finding of a causal relation between complications and type of mutilation indicates that the more brutal the type of procedure, the worse the complication. Yet, as has been advocated, there can be no justification for even excision of the prepuce in type I female genital mutilation. Advocating mild forms of cutting can raise the possibility of a dubious refocusing to appease cultural sensitivity sentiments. (excerpt)
MCH News. 1996 May; (2):6-7.Prolonged and obstructed labour are important causes of both maternal and perinatal morbidity and mortality. In the early 1970s, Hugh Philpot designed and developed the partograph in Zimbabwe to help prevent such problems and adverse outcomes during the active management of labour. He showed that the partograph helped to reduce prolonged labour, caesarian sections, labour augmentation and perinatal deaths. Anecdotal reports also mentioned of how the partograph made the occurrence of ruptured uteri much rarer, and implied that it had contributed to a reduction in maternal mortality. Anyone with experience of working in deprived areas where maternal care is predominantly managed by poorly supported midwives, and where the expertise for doing an emergency hysterectomy is limited or non-existent, will testify to the great value of the partogram. And yet, more than twenty years since its development, the partogram is still infrequently and inconsistently used in this country (both in rural and urban areas). (excerpt)
WHO indicators for evaluation of maternal health care services, applicability in least developed countries : a case study from Eritrea. [Indicateurs de l'OMS pour l'évaluation des services de santé maternelle, applicabilité dans les pays les moins développés : étude cas de l'Ethiopie]
African Journal of Reproductive Health. 2002 Aug; 6(2):13-22.The World Health Organization has recommended a number of process indicators to monitor the effect of health care programmes on maternal mortality. This study was therefore conducted to know if the recommended process indicators are useful also in the least developed countries. In 1994, all 17 health facilities offering maternal health care in a rural province in Eritrea were visited. An assessment was made of the obstetric services provided, obstetric complications, and accessibility of health facilities. The study revealed that necessary data were available for most indicators. The indicators were helpful to follow the coverage of obstetric care and to identify problems within the health care system. However, in countries where the coverage of assisted deliveries is low with few obstetric complications seen within the health care system, the indicators cannot be used as a tool to monitor the effect of maternal health care programmes on maternal mortality. (author's)
SAFE MOTHERHOOD. 1996; (20):1.Interventions that are routine at births around the world may be "unhelpful, untimely, inappropriate, and/or unnecessary" according to a WHO expert group. Only interventions that support the process of normal birth should be used and many that are poorly evaluated or potentially harmful should done away with. WHO's Technical Working Group on Normal Birth met in Geneva from March 25 to 29 this year. The group came up with a working definition of what normal birth includes and assessed whether various routine interventions really do bring benefit to mother or infant. In quite a few cases, the group found, interventions that are routine simply cannot be justified. Since most births are normal it is both wasteful and wrong to treat them all as if they were complicated, the members of the Technical Working Group said. (full text modified)
[Unpublished] 1991. 13 p. (WHO/VDT/91.455)The epidemiology, determining factors, prevention, detection, treatment, and programmatic aspects of maternal and congenital syphilis are discussed. Syphilis can be an acute or chronic infection, but is entirely curable; yet, it is one of the most damaging of all STDs to the fetus. Prevalence in maternal serum ranges from about 0.03% in the UK to 13-16% in some African urban areas. The adverse effects of untreated maternal syphilis to the fetus include abortion, intrauterine death, prematurity, congenital syphilis, and tardive infection. The infant is at greater risk if his mother's syphilis infection is acute; he may escape infection if her syphilis is chronic. Common barriers to effective control of syphilis in developing countries are late prenatal care, lack of screening or treatment, and, especially, failure to find a new infection after earlier prenatal screening. To prevent syphilis in pregnancy, the most important program approaches are health education and promotion of prenatal screening, adequate treatment, partner tracing, and treatment. Both in developing and Westernized settings, it is highly cost-effective to screen and treat maternal syphilis. In developing countries, the VDRL or rapid plasma reagin (RPR) card tests are adequate for screening. Programs should include the management techniques of training, evaluation, regular reporting, quality control of testing, and surveillance of maternal syphilis rates. All these systems can be linked to HIV testing and surveillance programs.
PROGRESS IN HUMAN REPRODUCTION RESEARCH. 1992; (23):2-3.A study sponsored by the Special Program of Research, Development and Research Training in Human Reproduction of the World Health Organization was carried out in Thailand involving groups of women with 1573 accidental pregnancies. There were 830 accidental pregnancies while using the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), while 743 women had become pregnant before use. There were also 601 accidental pregnancies in oral contraceptive (OC) users. The comparison group of a total of 2587 controls comprised women whose pregnancies were planned as opposed to the exposed group. Women using DMPA had more pregnancy risk factors compared to other groups owing to low socioeconomic status, lower maternal weight and height, smoking and alcohol use during pregnancy, and unplanned pregnancy. However, even after adjusting for these factors, DMPA users had a 50% higher than normal risk of having a low-birth-weight child. The same level of statistically not significant risk was also found among the OC users. Among those who had had accidental pregnancies during DMPA use, and in whom conception was estimated to have occurred within 4 weeks of a DMPA injection, the risk of low birth weight was 90% higher than that in the control group. The increase in risk appeared to decline to 50% when the interval between conception and DMPA injection was 5-8 weeks, and to 20% when the interval between conception and DMPA injection was 5-8 weeks, and to 20% when the interval was >or= 9 weeks. This trend was highly significant. Early, high-dose exposure in utero to DMPA seemed to affect fetal growth. There was no increase in the risk of mortality in the 1st year of life for infants exposed to OCs as compared to infants not exposed. However, infants from DMPA-exposed pregnancies had an 80% higher than normal risk of dying during the 1st year of life. Therefore, some infants born out of accidental pregnancies that occur during DMPA use may be at an increased risk of infant death.
Maternal anthropometry for prediction of pregnancy outcomes: memorandum from a USAID/WHO/PAHO/MotherCare meeting.
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1991; 69(5):523-32.The memorandum is an abbreviated version of a prepared report on maternal anthropometry which summarizes the general recommendations of a consensus of 50 experts on field applications and priority research issues in developing countries. Consensus was reached at a meeting on Maternal Anthropometry for Prediction of Pregnancy Outcomes held in Washington, D.C. in April 1990. 15 general recommendations are identified for field applications and research priorities. Specific recommendations differentiating field applications from research priorities are provided for prepregnancy weight, weight gain in pregnancy, height, arm circumference, and weight for height and body mass index. For example, the discussion of arm circumference indicates that it is useful as an indicator of maternal nutritional status in nonpregnant women because of its correlation with maternal weight or weight for height. During pregnancy, it is useful as a screen for risk of low birth weight (LBW) and late fetal and infant mortality. Maternal arm circumference has been found to be stable during pregnancy in developing countries and is independent of gestational age. Field applications involve the use 1) to assess the nutritional status of pregnant and nonpregnant women, 2) to screen women at risk of poor maternal stores postpartum because it reflects maternal fat and lean tissue stores, for instance, 3) to screen women and refer to facilities for a more thorough assessment of nutritional risk, and 4) to assess the extent of undernutrition in an area, particularly for surveillance. Community level workers, especially birth attendants (TBA's) should be trained and have access to arm circumference tapes. The technology is simple enough also for use by women in the home. Cutoff points for assessing biological risk are fairly consistent across developing country populations, and range between 21-23.5 cm. Routine monitoring during pregnancy is not necessary because the changes are too small to detect. Where prepregnancy weight is unavailable and weight is monitored, arm circumference may serve as a proxy for prepregnancy weight. All women of childbearing age should be measured. Research priorities are to explore the functional significance with women of difference body compositions (fat versus lean upper arm), the relationship to pregnancy related outcomes, arm changes relative to stages throughout the reproductive period and to weight changes, different instruments such as color-coded tapes or 1 tape for arm measurement and uterine height, combinations of different measurements, the relationship with prepregnancy weight, and the development of arm circumference in weight gain charts as a proxy for prepregnancy weight.