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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.
Contraception Report. 1999 Jan; 9(6): p..A recent WHO-sponsored study has demonstrated that the progestin levonorgestrel, used alone, is a highly effective and well-tolerated form of emergency contraception. With the proportion of pregnancies prevented up to 95% - depending on the timeliness of administration - the levonorgestrel regimen proved more effective than the most commonly used regimen, the Yuzpe method. The Yuzpe method employs a dual-hormone (ethinyl estradiol plus levonorgestrel) approach to preventing pregnancy. Despite the Yuzpe regimen's 75% efficacy rate (a weighted average from 10 studies) the method has been associated with drawbacks. About 50% of users experience nausea and 20% report vomiting, which can reduce patient compliance. (excerpt)
Lancet. 2005 Oct 8; 366(9493):1264.We appreciate the interest shown by Diana Mansour and Ian Fraser in our statement on the WHO “missed pill” recommendations. Our Clinical Effectiveness Unit provides objective statements on new publications in the field of contraception to assist members of the UK Faculty of Family Planning and Reproductive Health Care in their decisions about adopting new evidence into practice. Mansour and Fraser make a number of criticisms about our statement. First, they question the ability of pill users to interpret and apply the new missed pill rules. Our unit’s guidance is aimed at family planning clinicians, rather than contraceptive users. Although we assume that most women know the name and type of their pill and would be able to apply the recommendations, our statement was designed for clinicians rather than patients. The fpa (formerly the Family Planning Association) has published the same information in a format designed for women. (excerpt)
Contraception. 2004 May; 69(5):347-351.A recent review article by Smith et al. in The Lancet purports to find a causal relationship between long-term use of oral contraceptives (OCs) and cervical cancer. While we endorse the search for such a relationship, we felt it important to critically examine Smith et al.’s review process and, as a result, we have questions about the validity of their conclusions. In our view, the findings of published articles as presented by Smith et al. do not confirm a causal connection between long-term use of OCs and cervical cancer. Our goal is not to conduct another formal review of the evidence, but to evaluate whether Smith et al. have met the burden of proof for establishing a causal relationship. Given the importance of OCs to women the world over, we urge reproductive health professionals to consider this issue carefully before accepting that a causal relationship exists. (author's)
Washington, D.C., World Bank, 1994. x, 31 p. (World Bank Discussion Paper 258; Africa Technical Department Series)The Botswana 1984 Family Health Survey and the Zimbabwe 1984 Reproductive Health Survey (both contraceptive prevalence surveys), the 1988 Botswana Family Health Survey-II (a Demographic and Health Survey), and the 1988 Zimbabwe Demographic and Health Survey were performed to assess the extent of fertility and contraceptive use. Comparisons between surveys for both countries revealed that the fertility decline was not as dramatic as reported. Sample selection and questionnaire construction between surveys had changed sufficiently to account for some of the fertility decline. The sample in 1988 included more educated women even in the same cohort who had lower fertility. Also, the second DHS type survey asked for a complete birth history, which substantiated the actual number of children. In Zimbabwe, fertility was estimated at 6.5 in 1984 and 5.5 in 1988. The average was 3.4 children per woman in 1984 and 2.95 in 1988. The number of children ever born for women 45-49 years old declined from 7.5 to 6.9. During this period, improvements had been made in contraceptive usage, educational attainment, and health services. A comparison with census data showed that fertility was closer between 1984 and 1988 and significantly improved over fertility in 1969. In Botswana, total fertility declined from 6.5 to 5.0, and the number of children ever born decline from 6.9 to 5.8. The average number of children per woman declined from 3.1 to 2.6. Social development had occurred in Botswana also. There is some evidence that the age range of study participants, 15-49 years, may have excluded women at the extreme ends. About 20-50% of the fertility decline reported in Zimbabwe could be attributed to educational differences among women 25-34 years old. Similarly, in Botswana, among women 35-44 years old, 20-30% of the fertility decline could be attributed to educational changes.