Articles

Maternal immunisation to improve the health of HIV-exposed infants

HIV-exposed but uninfected (HEU) infants are at an increased risk of many infectious diseases that can contribute to the high mortality seen among HEU children. Maternal immunisation could be a promising strategy to reduce infections in HEU infants. However, very little research has explored the effect of HIV on the immunogenicity and effectiveness of vaccines given during pregnancy. The authors reviewed the available evidence on maternal immunisation among women living with HIV (WLWH) for all vaccines recommended, considered, or being investigated for routine or risk-based use during pregnancy. Of the 11 vaccines included, only three have been investigated in WLWH. Available evidence suggests that maternal HIV infection limits the immunogenicity of several vaccines, leaving HEU infants more susceptible to infection during their first few months of life. Whether maternal immunisation reduces the infectious morbidity and mortality associated with infectious diseases in HEU children remains unknown.

Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions

The study authors did a multicountry analysis of data from nationally representative Service Provision Assessment surveys done between 2007 to 2017 in ten countries across three regions (Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda). Findings suggest that there are critical gaps in the provision of post-abortion care at all facilities that offer delivery services. In seven (70%) of ten countries, less than 10% of primary-level facilities could provide basic post-abortion care, and in eight (80%) of ten countries less than 40% of referral-level facilities could provide comprehensive post-abortion care. In no country could all referral facilities provide all the essential services that need to be included in basic post-abortion care. Increasing the provision of good-quality post-abortion care is essential to reduce the level of abortion-related morbidity and mortality.

Perinatal outcomes in twin pregnancies complicated by maternal morbidity: evidence from the WHO Multicountry Survey on Maternal and Newborn Health

The objective of the preset study is to evaluate perinatal outcomes associated with twin pregnancies, stratified by severe maternal morbidity and order of birth. 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. Findings suggest that twin pregnancy is significantly associated with severe maternal morbidity and with worse perinatal outcomes, especially for the second twin.

National estimates and risk factors associated with early mother-to-child transmission of HIV after implementation of option B+: a cross-sectional analysis

Malawi's Ministry of Health led the National Evaluation of Malawi's PMTCT Program to obtain nationally representative data on maternal ART coverage and prevention of mother-to-child transmission (MTCT) effectiveness. This paper presents the early transmission data for infants aged 4–12 weeks. In multivariable logistic regression analysis, the odds of early MTCT were higher in mothers starting ART post partum (adjusted odds ratio 16·7, 95% CI 1·6–171·5; p=0·022) and in those not on ART with an unknown HIV status during pregnancy (19·1, 8·5–43·0; p<0·0001) than in mothers on ART before pregnancy. Among HIV-exposed infants, 98·0% (95% CI 96·9–99·1) were reported by the mother to have received infant nevirapine prophylaxis, and only 45·6% (34·8–56·4) were already enrolled in an exposed infant HIV care clinic at the time of study screening. These data suggest that Malawi's decentralisation of ART services has resulted in higher ART coverage and lower early MTCT. However, the uptake of services for HIV-exposed infants remains suboptimal.

Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis

These findings suggest that preterm birth remains a crucial issue in child mortality and improving quality of maternal and newborn care. To better understand the epidemiology of preterm birth, the quality and volume of data needs to be improved, including standardisation of definitions, measurement, and reporting.

Population-based rates, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa: a multi-country prospective cohort study.

In this prospective cohort study done in 11 community-based research sites in south Asia and sub-Saharan Africa, between July, 2012, and February, 2016, the authors conducted population-based surveillance of women of reproductive age (15-49 years) to identify pregnancies, which were followed up to birth and 42 days post partum. These results will contribute to improved global estimates of rates, timing, and causes of maternal and newborn deaths and stillbirths. The findings imply that programmes in sub-Saharan Africa and south Asia need to further intensify their efforts to reduce mortality rates, which continue to be high. The focus on improving the quality of maternal intrapartum care and immediate newborn care must be further enhanced. Efforts to address perinatal asphyxia and newborn infections, as well as preterm birth, are critical to achieving survival goals in the Sustainable Development Goals era.

Short interpregnancy intervals and adverse perinatal outcomes in high-resource settings: An updated systematic review

This systematic review summarises association between short interpregnancy intervals and adverse perinatal health outcomes in high-resource settings to inform recommendations for healthy birth spacing for the United States. In high-resource settings, there is some evidence showing interpregnancy intervals <6 months since last livebirth are associated with increased risks for preterm birth, small-for-gestational age and infant death; however, results were inconsistent. Additional research controlling for confounding would further inform recommendations for healthy birth spacing for the United States.

Equity in antenatal care quality: an analysis of 91 national household surveys.

Using the most recent (2007-16) Demographic and Health Surveys and Multiple Indicator Cluster Surveys in 91 low middle income countries (LMICs), the authors described antenatal care quality based on receipt of three essential services (blood pressure monitoring and urine and blood testing) among women who had at least one visit with a skilled antenatal-care provider. FIndings suggest that many LMICs that have reached high levels of antenatal care coverage had much lower and inequitable levels of quality. Achieving ambitious maternal, newborn, and child health goals will require greater focus on the quality of health services and their equitable distribution. Equity in effective coverage should be used as the new metric to monitor progress towards universal health coverage.

Interventions to reduce unnecessary caesarean sections in healthy women and babies

In this Series paper, the author describe the factors for caesarean section (CS) use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women's and health professionals' concerns, as well as health system and financial factors.

Treatment modalities for pregnant women with opioid use disorder

the authors compared the efficacy and safety of detoxification from opioids compared with opioid replacement therapy (ORT) during pregnancy. indings suggest an increased risk of relapse with detoxification treatment compared with ORT; however, detoxification does not alter the risk of preterm birth or neonatal abstinece syndrome. Further studies should confirm our findings and explore mechanisms to fight the current opioid epidemic.

How much do conditional cash transfers increase the utilization of maternal and child health care services? New evidence from Janani Suraksha Yojana in India.

Janani Suraksha Yojana (safe motherhood scheme, or JSY) provides cash incentives to marginal pregnant women in India conditional on having mainly institutional delivery. Using the fourth round of district level household survey (DLHS-4), we have estimated its effects on both intended and unintended outcomes. Our estimates of average treatment effect on the treated (ATT) from propensity score matching are remarkably higher than those found in previous prominent studies using the second and third rounds of the survey (DLHS-2 and DLHS-3). When we apply fuzzy regression discontinuity design exploiting the second birth order, our estimates of local average treatment effect (LATE) are much higher than that of ATT. For example, due to JSY, institutional delivery increases by around 16 percentage points according to ATT estimate but about 23 percentage points according to LATE estimate.

Stillbirths count, but it is now time to count them all

In 2015, 2·6 million stillbirths were estimated globally, more than 7100 deaths a day, with most occurring in developing countries. These figures are substantial, yet they are an underestimation of the full extent of this loss because stillbirths at less than 28 weeks of pregnancy are not included in these numbers. If the 22-week threshold was applied, the numbers have been estimated to be 40% higher. 

Global Abortion Policies Database: a new approach to strengthening knowledge on laws, policies, and human rights standards

The GAPD is a comprehensive tool that can be used to strengthen knowledge, inform law and policy research to generate evidence on the impact of laws and policies in practice, and facilitate greater awareness of the many challenges to creating enabling policy environments for safe abortion.

Trends in adolescent first births in five countries in Latin America and the Caribbean: disaggregated data from demographic and health surveys

The study draws on Demographic and Health Survey data from five countries where three surveys are available since 1990, with the most recent after 2006. It examines trends in adolescent births by wealth status and urban/rural residence. The study draws on Demographic and Health Survey data from five countries where three surveys are available since 1990, with the most recent after 2006. It examines trends in adolescent births by wealth status and urban/rural residence.

Measuring health inequalities in the context of sustainable development goals

The World Health Organization has developed a multistep approach to health inequality monitoring consisting of: (i) determining the scope of monitoring; (ii) obtaining data; (iii) analysing data; (iv) reporting results; and (v) implementing changes. This paper presents some technical considerations for developing or strengthening health inequality monitoring, with the aim of encouraging more robust, systematic and transparent practices. It discusses key aspects of measuring health inequalities that are relevant to steps (i) and (iii). 

Population-level factors associated with maternal mortality in the United States, 1997–2012

The authors analyzed state-level maternal mortality for the years 1997–2012 using multilevel mixed-effects regression grouped by state, using publicly available data including whether a state had adopted the 2003 U.S. Standard Certificate of Death, designed to simplify identification of pregnant and recently pregnant decedents. Findings indicate that, in addition to better case ascertainment of maternal deaths, adverse changes in chronic diseases, insufficient healthcare access, and social determinants of health represent identifiable risks for maternal mortality that merit prompt attention in population-directed interventions and health policies.

Burden of disease in Brazil, 1990–2016: a systematic subnational analysis for the Global Burden of Disease Study 2016

Clinicians’ views of factors influencing decision-making for caesarean section: A systematic review and metasynthesis of qualitative, quantitative and mixed methods studies

This systematic review aimed to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report obstetricians’ and midwives’ views on the factors that influence the decision to perform caesarean section. This systematic review and metasynthesis identified clinicians’ personal beliefs as a major factor that influenced the decision to perform caesarean section, further contributed by the influence of factors related to the health care system and clinicians’ characteristics. Obstetricians and midwives are directly involved in the decision to perform a caesarean section, hence their perspectives are vital in understanding various factors that have influence on decision-making for caesarean section. These results can help clinicians identify and acknowledge their role as crucial members in the decision-making process for caesarean section within their organisation, and to develop intervention studies to reduce caesarean section rates in future. 

Early initiation of breastfeeding: The best start for every newborn

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