Safety and effectiveness of intravenous iron sucrose versus standard oral iron therapy in pregnant women with moderate-to-severe anaemia in India: a multicentre, open-label, phase 3, randomised, contrby Neogi et al
The authors aimed to assess the safety and clinical effectiveness of intravenous iron sucrose (intervention) versus standard oral iron (control) therapy in the treatment of women with moderate-to-severe iron deficiency anaemia in pregnancy. The study was stopped due to futility. There is insufficient evidence to show the effectiveness of intravenous iron sucrose in reducing clinical outcomes compared with standard oral iron therapy in pregnant women with moderate-to-severe anaemia.
Association of maternal antiretroviral use with microcephaly in children who are HIV-exposed but uninfected (SMARTT): a prospective cohort studyby Williams et al
The authors evaluated children aged younger than 18 years who were HIV-exposed but uninfected with at least one head circumference measurement while enrolled in the Surveillance Monitoring for ART Toxicities (SMARTT) study at 22 clinical sites in the USA, including Puerto Rico. These findings support consideration of alternatives to efavirenz as part of first-line antiretroviral therapy for pregnant women.
Medical and non-medical reasons for cesarean section delivery in Egypt: a hospital-based retrospective study.by Elnakib S. et al.
This study sought to (1) explore indications and risk factors for Caesarean section (CS) in public hospitals in four governorates in Egypt and (2) examine health care provider factors impacting the decision to perform a CS. Findings suggestA combination of both medical and non-medical factors drives the increase in CS rates. Our analysis however suggests that a substantial number of CS deliveries took place in the absence of strong medical justification. Health care provider factors seem to be powerful factors influencing CS rates in the study hospitals.
How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveysby Bohren MA. et al.
The authors aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries. Findings suggest that more than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context.
Impact of group antenatal care (G-ANC) versus individual antenatal care (ANC) on quality of care, ANC attendance and facility-based delivery: A pragmatic cluster-randomized controlled trialby Grenier L. et al
Low quality and frequency of antenatal care (ANC) are associated with lower uptake of facility-based deliveries-a key intervention to reduce maternal and neonatal mortality. The authors implemented group ANC (G-ANC), an alternative service delivery model, in Kenya and Nigeria, to assess its impact on quality and attendance at ANC and uptake of facility-based delivery. Findings suggest that G-ANC was associated with higher facility-based delivery rates in Nigeria, where those rates associated with individual ANC were low. In both Kenya and Nigeria it was associated with a higher proportion of women receiving quality ANC and higher frequency of ANC visits.
Risk of adverse perinatal outcomes among women with pharmacologically treated and untreated depression during pregnancy: A retrospective cohort studyby Adhikari et al
This study examined the risks of adverse perinatal outcomes associated with antidepressant use during pregnancy. Both depression and antidepressant use were independently associated with the risk of adverse perinatal outcomes; however, the risk associated with antidepressants was higher over and above the risk associated with depression. This may reflect the biological effects of antidepressants, greater severity of depression in those treated, or both.
Home childbirth among young mothers aged 15-24 years in Nigeria: a national population-based cross-sectional studyby Adewuyi et al
A secondary analysis of cross-sectional data from the 2013 Nigeria Demographic and Health Survey (NDHS) was done to estimate the prevalence and identify factors associated with home childbirth (delivery) among young mothers aged 15-24 years in Nigeria. Findings suggest that young mothers aged 15-24 years had a higher prevalence of home delivery than the national average for all women of reproductive age in Nigeria.
Post-partum family planning in Burkina Faso (Yam Daabo): a two group, multi-intervention, single-blinded, cluster-randomised controlled trial.by Taon Tran et al
This study assessed the effect of a family planning intervention package on modern contraceptive use at 12 months post partum in predominantly rural Burkina Faso. Findings suggest that a package of six low-technology interventions, aimed at strengthening existing primary health-care services and enhancing demand for these services, can effectively increase modern contraceptive use for up to a year post partum in rural settings in Burkina Faso and has the potential to be suitable in similar settings in this country and others.
Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trialsby Gabrysch et al
This study is a secondary analysis of surveillance data on 119 244 pregnancies from two large population-based cluster-randomised controlled trials in Brong Ahafo, Ghana. Findings suggest that facility birth does not necessarily convey a survival benefit for women or babies and should only be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safe-guarding uncomplicated births.
Caesarean delivery rates in Mexico are among the highest in the world. Given heightened public and professional awareness of this problem and the updated 2014 national guidelines to reduce the frequency of caesarean delivery, the authors analysed trends in caesarean delivery by type of facility in Mexico from 2008 to 2017. Findings suggest that since 2014, rates of caesarean delivery have fallen slightly in all sectors, but they remain high at 45.5%. Policies with appropriate interventions are needed to reduce the caesarean delivery rate in Mexico, particularly in private-sector hospitals.
Screening for HIV Infection in Pregnant Women: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.by Selph et al
The US Preventive Services Task Force (USPSTF) previously found strong evidence that prenatal HIV screening reduced risk of mother-to-child transmission. The previous evidence review was conducted in 2012. Findings suggest that combination ART was highly effective at reducing risk of mother-to-child HIV transmission. Use of certain ART regimens during pregnancy was associated with increased risk of harms that may be mitigated by selection of ART regimen. The 2012 review found that avoidance of breastfeeding and cesarean delivery in women with viremia also reduced risk of transmission and that prenatal screening accurately diagnosed HIV infection.
Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trialby Knight et al
The authors aimed to investigate whether antibiotic prophylaxis prevented maternal infection after operative vaginal birth. In a blinded, randomised controlled trial done at 27 UK obstetric units, women (aged ≥16 years) were allocated to receive a single dose of intravenous amoxicillin and clavulanic acid or placebo (saline) following operative vaginal birth at 36 weeks gestation or later. The primary outcome was confirmed or suspected maternal infection within 6 weeks of delivery defined by a new prescription of antibiotics for specific indications, confirmed systemic infection on culture, or endometritis. This trial shows benefit of a single dose of prophylactic antibiotic after operative vaginal birth and guidance from WHO and other national organisations should be changed to reflect this.
Lack of safe, affordable, medically indicated caesarean delivery is a primary contributor to global health inequity. In low-income and middle-income countries (LMICs), it perpetuates preventable morbidity and mortality caused by prolonged or obstructed labour. Adequate intervention alone would avert 1 million disability-adjusted life-years (DALYs), with a median benefit-to-cost ratio of 6·0 at US$304 per DALY averted, reflecting an eradicable burden of disease that undermines sustainable development, economic growth, and human rights.
National, regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: a systematic analysisby Blencowe et al.
The authors aimed to assist in setting a baseline against which to assess progress towards the achievement of the World Health Assembly targets for reductions in low birth weight (LBW) prevalence. The authors collated data on 1447 country-years of birthweight data (281 million births) for 148 countries of 195 UN member states (47 countries had no data meeting inclusion criteria). The estimated worldwide LBW prevalence in 2015 was 14·6% compared with 17·5% in 2000 (average annual reduction rate 1·23%). In 2015, an estimated 20·5 million livebirths were LBW, 91% from low-and-middle income countries, mainly southern Asia (48%) and sub-Saharan Africa (24%).
The authors conducted a multicenter, randomized, double-blind, placebo-controlled trial to evaluate progesterone, as compared with placebo, in women with vaginal bleeding in early pregnancy. The findings suggest that among women with bleeding in early pregnancy, progesterone therapy administered during the first trimester did not result in a significantly higher incidence of live births than placebo.
The objective of the study was to examine the association of ranges of gestational weight gain with risk of adverse maternal and infant outcomes and estimate optimal gestational weight gain ranges across prepregnancy body mass index categories. Individual participant-level meta-analysis using data from 196 670 participants within 25 cohort studies from Europe and North America (main study sample) was conducted. In this meta-analysis of pooled individual participant data from 25 cohort studies, the risk for adverse maternal and infant outcomes varied by gestational weight gain and across the range of prepregnancy weights. The estimates of optimal gestational weight gain may inform prenatal counseling; however, the optimal gestational weight gain ranges had limited predictive value for the outcomes assessed.
Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysisby Sobhy S. et al
Universal and timely access to a caesarean section is a key requirement for safe childbirth. This review identified the burden of maternal and perinatal mortality and morbidity, and the risk factors following caesarean sections in low-income and middle-income countries (LMICs). The review included 196 studies from 67 LMICs. The risk of maternal death in women who had a caesarean section was 7·6 per 1000 procedures; the highest burden was in sub-Saharan Africa (10·9 per 1000). A quarter of all women who died in LMICs had undergone a caesarean section. Maternal deaths and perinatal deaths following caesarean sections are disproportionately high in LMICs. The timing and urgency of caesarean section pose major risks.
Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzaniaby Geldsetzer P. et al
This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home. A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC.
Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort studyby Bishop et al
A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. Findings suggest that maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa.
Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment toolsby Brizuela et al
The authors aimed to assess the capacity of globally used, large-scale facility assessment tools to measure quality of maternal and newborn care as per the WHO framework. Findings suggest that existing facility assessment tools provide a valuable way to assess quality of maternal and newborn care as one element within the national measurement toolkit. Guidance is clearly needed on priority measures and for better harmonisation across tools to reduce measurement burden and increase data use for quality improvement. Targeted development of measurement modules to address important gaps is a key priority for research.
Effect of a novel vital sign device on maternal mortality and morbidity in low-resource settings: a pragmatic, stepped-wedge, cluster-randomised controlled trialby Vousdin et al
The primary aim of this trial was to determine whether implementation of the CRADLE Vital Sign Alert and an education package into community and facility maternity care in low-resource settings could reduce a composite of all-cause maternal mortality or major morbidity (eclampsia and hysterectomy) across Africa, India, and Haiti. There was an absolute 8% reduction in primary outcome during the trial, with no change in resources or staffing, but this reduction could not be directly attributed to the intervention due to variability. The authors encountered unanticipated methodological challenges with this trial design, which can provide valuable learning for future research and inform the trial design of future international stepped-wedge trials.
Utilization of Long-Acting Reversible Contraceptives in the United States After vs Before the 2016 US Presidential Electionby Pace LE et al
Using data from a large sample of commercially insured women, the authors sought to assess whether there was an increase in long-acting reversible contraceptive (LARC) utilization among commercially insured women during the 30 days after the election, compared with the 30 days before the election and the same period in 2015.
Inherited predisposition to stillbirth: an intergenerational analysis of 26,788 mother-daughter pairsby Woolner AMF et al
The aim of the study was to investigate if there is an inherited predisposition to stillbirth transmitted from mother to daughter. The findings suggest that among the daughters, 384 had a history of one or more stillbirths (cases) while 26,404 only ever had livebirths (controls). We found no statistically significant association between mothers' history of stillbirth (adjusted Odds Ratio (aOR) 0.63; 95% CI 0.24-1.63) or miscarriage (aOR 1.01; 95% CI 0.71-1.42) and stillbirth in daughters.
Quality of care in early detection and management of pre-eclampsia/eclampsia in health facilities in Afghanistanby Ansari N et al
The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment assessed quality of early detection and management of PE/E in health facilities and skilled birth attendants' (SBAs) perceptions of their working environment. Notable gaps in SBAs' knowledge and clinical practices in detection and management of PE/E in various health facilities increase the risk of maternal and perinatal mortality. Continuing education of health care providers and increased investment in focused quality improvement initiatives will be critical to improve the quality of health care services in Afghanistan.
Capacities of women and men to improve maternal and newborn health: Effect of a community-based intervention package in rural Bangladeshby Rahman AE et al
A community-based intervention package was initiated in 2009 in Netrokona, a rural district in Bangladesh, to engage individuals, families and communities to improve maternal and newborn health. In this article, the authors present the effect of the intervention package on improvement of women's capacities with regard to maternal and newborn health, their husbands' capacities to effectively support them and use of skilled services during pregnancy, childbirth and after childbirth. The authors conclude that the intervention package was effective in building the capacities of women and in engaging their husbands positively in maternal and newborn health. This may have translated into increased use of skilled care during pregnancy.
The objective was to perform a systematic review of indicators for the central phases of the maternal and child healthcare continuum of care (pregnancy, childbirth, newborn care and postpartum). Findings suggest that there is a broad choice of indicators for maternal and child healthcare. However, most indicators lack demonstrated scientific soundness and refer to particular continuum phases and levels within the healthcare system. Additional efforts are needed to identify good indicators for a comprehensive maternal and child healthcare monitoring system.
Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and Indiaby Afulani et al
The authors examined data from four cross-sectional surveys with 3625 women aged 15-49 years who had recently given birth in Kenya, Ghana, and India (surveys were done from August, 2016, to October, 2017). Fndings suggest that regardless of the setting, women are not getting adequate PCMC. Efforts are needed to improve the quality of facility-based maternity care.
Maternal mortality ratios in 2852 Chinese counties, 1996–2015, and achievement of Millennium Development Goal 5 in China: a subnational analysis of the Global Burden of Disease Study 2016by Liang et al
Using a national registration system of maternal mortality at the county level, the authors estimated the maternal mortality ratios for 2852 counties in China between 1996 and 2015. Findings suggest that in the past two decades, maternal mortality ratios have reduced rapidly and universally across China at the county level. Fast improvement in maternal mortality ratios is possible even in less economically developed places with resource constraints. This finding has important implications for improving maternal mortality ratios in developing countries in the Sustainable Development Goal era.
The conducted a scoping review of indicators proposed by global multi-stakeholder groups to suggest next steps to further support maternal and newborn measurement and monitoring. The authors identified 140 indicators linked to maternal and newborn health topics across the continuum of service provision. Fifty-five indicators relate to inputs and processes, 30 indicators relate to outputs, outcomes comprise 37 indicators in the database, and 18 impact indicators. A quarter of indicators proposed by global groups is either under development/discussion or is considered "aspirational", highlighting the currently evolving monitoring landscape. Although considerable efforts have been made to harmonize indicator recommendations, there are still relatively few indicators shared across key monitoring initiatives and some of those that are shared may have definitional variation.
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.
Perinatal outcomes in twin pregnancies complicated by maternal morbidity: evidence from the WHO Multicountry Survey on Maternal and Newborn Healthby Santana et al
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 analysisby Beth A Tippett Barr et al
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 analysisby Chawanpaiboon S et al
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.by The Alliance for Maternal and Newborn Health Improvement (AMANHI) mortality study group
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 reviewby Ahrens et al
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.
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.
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.
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.by Rahman MM et al
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.
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 standardsby Ronald Johnson Jr et al
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 surveysby Neal et al
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.
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.
Clinicians’ views of factors influencing decision-making for caesarean section: A systematic review and metasynthesis of qualitative, quantitative and mixed methods studiesby Panda et al
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.
Impact of integrating a postpartum family planning program into a community-based maternal and newborn health program on birth spacing and preterm birth in rural Bangladeshby Baqui et al
In a quasi-experimental trial design, unions with an average population of about 25 000 and a first level health facility were allocated to an intervention arm (n = 4) to receive integrated post-partum family planning and maternal and newborn health (PPFP-MNH) interventions, or to a control arm (n = 4) to receive the MNH interventions only. Study findings demonstrate the feasibility and effectiveness of integrating PPFP interventions into a community based MNH intervention package. Thus, MNH programs should consider systematically integrating PPFP as a service component to improve pregnancy spacing and reduce the risk of preterm birth.
This large trial compared a novel formulation of heat-stable carbetocin with oxytocin. The study enrolled women across 23 sites in 10 countries in a randomized, double-blind, noninferiority trial comparing intramuscular injections of heat-stable carbetocin (at a dose of 100 μg) with oxytocin (at a dose of 10 IU) administered immediately after vaginal birth. Findings suggest that heat-stable carbetocin was noninferior to oxytocin for the prevention of blood loss of at least 500 ml or the use of additional uterotonic agents. Noninferiority was not shown for the outcome of blood loss of at least 1000 ml; low event rates for this outcome reduced the power of the trial.
The objective was to determine whether low dose aspirin reduces the rate of spontaneous PTB in nulliparous women without medical co-morbidities. This is a secondary analysis of a randomized, placebo-controlled trial of low dose aspirin for prevention of preeclampsia in healthy, low-risk, nulliparous women. Low dose aspirin is associated with a substantial decrease in spontaneous PTB <34wks in healthy nulliparous women without co-morbidities. These findings suggest a new therapeutic option for PTB prevention that requires further study.
Improvement in the active management of the third stage of labor for the prevention of postpartum hemorrhage in Tanzania: a cross-sectional studyby Bishanga et al
A cross-sectional study was conducted in 52 health facilities in Tanzania utilizing direct observations of women during labor and delivery. Findings suggets that the quality of PPH prevention increased substantially in facilities that implemented competency-based training and quality improvement interventions, with the most dramatic improvement seen at lower-level facilities. As Tanzania continues with efforts to increase facility births, it is imperative that the quality of care also be improved by promoting use of up-to-date guidelines and ensuring regular training and mentoring for health care providers so that they adhere to the guidelines for care of women during labor. These measures can reduce maternal and newborn mortality.
National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysisby Lange et al
Smoking during pregnancy has been linked to numerous adverse health consequences for both the developing fetus and mother. This study estimated the prevalence of smoking during pregnancy by country, WHO region, and globally and the proportion of pregnant women who smoked during pregnancy, by frequency and quantity, on a global level. The findings suggest that smoking during pregnancy is still a prevalent behaviour in many countries. These findings should inform smoking prevention programmes and health promotion strategies, as well as draw attention to the need for improved access to smoking cessation programmes for pregnant women.
Burden of physical, psychological and social ill-health during and after pregnancy among women in India, Pakistan, Kenya and Malawiby McCauley et al
For every woman who dies during pregnancy and childbirth, many more suffer ill-health, the burden of which is highest in low-resource settings. The study sought to assess the extent and types of maternal morbidity. Findings from this study suggests that women suffer significant ill-health which is still largely unrecognised. Current antenatal and postnatal care packages require adaptation if they are to meet the identified health needs of women.
The objective of this review is to assess the effects of a policy of labour induction at or beyond term compared with a policy of awaiting spontaneous labour or until an indication for birth induction of labour is identified) on pregnancy outcomes for infant and mother. A policy of labour induction at or beyond term compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections; but more operative vaginal births. NICU admissions were lower and fewer babies had low Apgar scores with induction. No important differences were seen for most of the other maternal and infant outcomes.
Effectiveness of a WHO Safe Childbirth Checklist Coaching-based intervention on the availability of Essential Birth Supplies in Uttar Pradesh, Indiaby Maisonneuve et al
The objective of this study was to evaluate the impact of a World Health Organization Safe Childbirth Checklist coaching-based intervention (BetterBirth Program) on availability and procurement of essential childbirth-related supplies. Implementation of the BetterBirth Program, incorporating supply availability, resulted in modest improvements with catch-up by control facilities by 12 months. Supply-chain coaching may be most beneficial in sites starting with lower supply availability. Efforts are needed to reduce reliance on patient-funding for some critical medications.
Increased risk of cardiovascular disease in women with prior gestational diabetes: A systematic review and meta-analysisby Li et al
This study aims to investigate the effect of gestational diabetes mellitus (GDM) on the long-term risk of cardiovascular disease (CVD). Seven cohort studies with 3,417,020 pregnant women including 14,146 incident CVD events were retrieved. In the pooled analysis, women with previous GDM had a higher risk of CVD than those without.
Not just a number: examining coverage and content of antenatal care in low-income and middle-income countriesby Benova et al
Antenatal care (ANC) provides a critical opportunity for women and babies to benefit from good-quality maternal care. Using 10 countries as an illustrative analysis, this study described ANC coverage (number of visits and timing of first visit) and operationalised indicators for content of care as available in population surveys, and examined how these two approaches are related. Findings suggest that even among women with patterns of care that complied with global recommendations, the content of care was poor. Efficient and effective action to improve care quality relies on development of suitable content of care indicators.
The effect of Kenya’s free maternal health care policy on the utilization of health facility delivery services and maternal and neonatal mortality in public health facilitiesby Gitobu et al
This paper aims to provide a brief overview of this policy’s effect on health facility delivery service utilization and maternal mortality ratio and neonatal mortality rate in Kenyan public health facilities. The findings suggest that cost is a deterrent to health facility delivery service utilization in Kenya and thus free delivery services are an important strategy to promote utilization of health facility delivery services; however, there is a need to simultaneously address other factors that contribute to pregnancy-related and neonatal deaths.
Women's experiences of mistreatment during childbirth: A comparative view of home- and facility-based births in Pakistanby Hameed et al
The aim of this epidemiological study was to estimate the prevalence of mistreatment and types of mistreatment among women giving birth in facility- and home-based settings in Pakistan in order to address the lack of empirical evidence on this topic. There were no significant differences in manifestations of mistreatment between facility- and home-based childbirths. Approximately 97% of women reported experiencing at least one disrespectful and abusive behaviour. Experiences of mistreatment by type were as follows: non-consented care (81%); right to information (72%); non-confidential care (69%); verbal abuse (35%); abandonment of care (32%); discriminatory care (15%); and physical abuse (15%).
Demand for family planning satisfied with modern methods among sexually active women in low- and middle-income countries: who is lagging behind?by Ewerling et al
The objective was to identify groups of sexually active women with extremely low demand for family planning satisfied with modern methods (mDFPS) in low- and middle-income countries, at national and subnational levels to inform the improvement and expansion of programmatic efforts to narrow the gaps in mDFPS coverage. Analyses were based on Demographic and Health Survey and Multiple Indicator Cluster Survey data. Almost half of the women in need were not using an effective family planning method. Subgroups requiring special attention include women who are poor, uneducated/illiterate, young, and living in rural areas. Efforts to increase mDFPS must address not only the supply side but also tackle the need to change social norms that might inhibit uptake of contraception.
Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countriesby Hahn-Holbrook et al
Postpartum depression (PPD) poses a major global public health challenge. The authors conducted a meta-analysis to estimate the global and national prevalence of PPD and a meta-regression to identify economic, health, social, or policy factors associated with national PPD prevalence. The global prevalence of PPD is greater than previously thought and varies dramatically by nation. Disparities in wealth inequality and maternal-child-health factors explain much of the national variation in PPD prevalence.
Active management of the third stage of labor (AMTSL) describes interventions with the common goal to prevent postpartum hemorrhage (PPH). A systematic search was conducted in five databases in September 2015 to identify intervention studies of AMTSL implemented by unskilled birth attendants or pregnant women themselves. Task shifting of AMTSL has thus far been evaluated for administration of uterotonics (misoprostol tablets and oxytocin injected by CHWs and auxiliary midwives) and resulted in reduction of PPH, high rates of appropriate use and satisfaction among users.
Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventionsby Tokhi et al
The objective of thsi review was to determine the effect of interventions to engage men during pregnancy, childbirth and infancy on mortality and morbidity, as well as effects on mechanisms by which male involvement is hypothesised to influence mortality and morbidity outcomes: home care practices, care-seeking, and couple relationships. Findings suggets that interventions to engage men in maternal and newborn health can increase care-seeking, improve home care practices, and support more equitable couple communication and decision-making for maternal and newborn health. These findings support engaging men as a health promotion strategy, although evidence gaps remain around effects on mortality and morbidity. Findings also indicate that interventions to increase male involvement should be carefully designed and implemented to mitigate potential harmful effects on couple relationship dynamics.
Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child healthby Countdown to 2030 Collaboration
To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.
Institutional setting and wealth gradients in cesarean delivery rates: Evidence from six developing countriesby Sepheri et al 2018
This study examined wealth-related variations in cesarean rates in six lower- and upper-middle income countries: the Dominican Republic, Egypt, Guatemala, Jordan, Pakistan, and the Philippines. Large wealth-related variations in the mode of delivery across government and private hospitals suggest the need for well-developed guidelines and standards to achieve a more appropriate selection of cases for cesarean delivery.
The Effect of the Removal of User Fees for Delivery at Public Health Facilities on Institutional Delivery in Urban Kenyaby Calhoun et al
This study determines the effect of the policy to remove user fees on institutional delivery in a population-based sample of women from urban Kenya. Multivariate findings show that women were significantly more likely to deliver at a public facility as compared to a private facility after the policy. Among the poor, the results show that poor women were significantly more likely to deliver in a public facility compared to home or a private facility after policy change.
Long-term risk of diabetes in women at varying durations after gestational diabetes: a systematic review and meta-analysis with more than 2 million womenby Song et al 2017
This study aims to investigate the impact of gestational diabetes mellitus (GDM) on the long-term risks of diabetes in women with prior GDM, including the effect at different time periods after GDM. Thirty cohort studies with 2,626,905 pregnant women were included. Women with prior GDM had 7.76-fold (95% confidence intervals: 5.10–11.81) unadjusted pooled risk of diabetes as compared with women without GDM, whilst the adjusted risk was 17.92-fold (16.96–18.94). The adjusted ORs of GDM for diabetes among women at <3, ≥3 – <6 and ≥6 – <10 years after GDM were 5.37 (3.51–9.34), 16.55 (16.08–17.04) and 8.20 (4.53–14.86), respectively. Women with prior GDM had substantially increased risk of diabetes, with the risk highest during the 3–6 years after GDM.
Randomized controlled pilot of a group antenatal care model and the sociodemographic factors associated with pregnancy-related empowerment in sub-Saharan Africaby Patil et al
The study compares pregnancy-related empowerment for women randomly assigned to the standard of care versus CenteringPregnancy-based group ANC (intervention) in two sub-Saharan countries, Malawi and Tanzania. Pregnant women in Malawi (n = 112) and Tanzania (n = 110) were recruited into a pilot study and randomized to individual ANC or group ANC. The findings suggest that Group ANC empowers pregnant women in some contexts. More research is needed to identify the ways that models of ANC can affect pregnancy-related empowerment in addition to perinatal outcomes globally.
The authors performed a systematic review and meta-analysis that evaluated the prophylactic effect of aspirin during pregnancy. Sixteen trials including 18,907 participants provided data for preterm and term preeclampsia. Findings suggest that Aspirin reduces the risk of preterm preeclampsia but not term preeclampsia, and only when it is initiated at ≤16 weeks of gestation and at a daily dose of ≥100 mg.
A Prospective Cause of Death Classification System for Maternal Deaths in Low and Middle-Income Countries: Results from the Global Network Maternal Newborn Health Registryby Pasha et al 2017
This study describe the causes of maternal death in a population-based cohort in six low and middle-income countries using a standardized, hierarchical, algorithmic cause of death (COD) methodology. Findings suggest that the major maternal COD in the Global Network sites were hemorrhage, pregnancy-related infection and preeclampsia/eclampsia. This system could allow public health programs in low and middle-income countries to generate transparent and comparable data for maternal COD across time or regions.
Effect of a package of integrated demand- and supply-side interventions on facility delivery rates in rural Bangladesh: Implications for large-scale programsby Rahman et al 2017
The study assessed the effect of integrated supply- and demand-side interventions on the facility-based delivery rate. Findings suggest that an integrated supply- and demand-side intervention was associated with a substantial increase in institutional delivery. The package can be tailored to identify which combination of interventions may produce the optimum result and be scaled. Rigorous implementation research studies are needed to draw confident conclusions and to provide information about the costs, feasibility for scale-up and sustainability.
Management of pregnancy at and beyond 41 completed weeks of gestation in low-risk women: a secondary analysis of two WHO multi-country surveys on maternal and newborn healthby Mya et al 2017
This study is a secondary analysis of the WHO Global Survey (WHOGS) and the WHO Multi-country Survey (WHOMCS) conducted in Africa, Asia, Latin America and the Middle East. There were 33,003 women with low risk singleton pregnancies at ≥41 completed weeks from 292 facilities in 21 countries. Compared to induction of labour (IOL), ECS significantly increased risk of NICU admission while EM was significantly associated with decreased risk of CS. ECS should not be recommended for women at 41 completed weeks of pregnancy. However, the choice between IOL and EM should be cautiously considered since the available evidences are still quite limited.
Racial disparities in comorbidity and severe maternal morbidity/mortality in the United States: an analysis of temporal trendsby Metcalfe A et al
Severe maternal morbidity and mortality have increased in the USA in recent years. This trend has not been consistent across all racial groups. The reasons behind this, and the relationship between pre-existing conditions, pregnancy-associated disease and Severe maternal morbidity/mortality, have not been fully explored. The findings suggest that the rate of both pre-existing comorbidities and pregnancy-associated disease is increasing in pregnant women in the USA and varies substantially by race. These trends provide valuable insight into the increasing complexity of pregnancy in the USA and explain a proportion of the observed increase in Severe maternal morbidity/mortality.
This paper draws on secondary data from 40 low and middle income countries that conducted emergency obstetric and newborn care assessments over the last 10 years. We reviewed 6.5 million deliveries, surveyed in 15,411 facilities. Most of the data were extracted from reports and aggregated with excel. Findings suggest that to a large extent, facility-based findings mirror what population-based systematic reviews have also documented. As coverage of a skilled attendant at birth increases, proportionally more deaths will occur in facilities, making improvements in record-keeping and health management information systems, especially for stillbirths and early neonatal deaths, all the more critical.
A look back on how far to walk: Systematic review and meta-analysis of physical access to skilled care for childbirth in Sub-Saharan Africaby Wong et al
The objectives of this review were to (i) summarize the methods undertaken to measure physical accessibility as the spatial separation between women and health services, and (ii) establish the extent to which distance to skilled care for childbirth affects utilization in Sub-Saharan Africa. Findings suggest that although the reporting and measurements of spatial separation in low-resource settings needs further development, we found evidence that a lack of geographic access impedes use. Utilization is conditioned on access, researchers and policy makers should therefore prioritize quality data for the evidence-base to ensure that women everywhere have the potential to access obstetric care.
Early antenatal care visit: a systematic analysis of regional and global levels and trends of coverage from 1990 to 2013by Moller et al
Systematic global analysis of early antenatal care visits has not been done previously. This study reports on regional and global estimates of the coverage of early antenatal care visits from 1990 to 2013. Findings suggest that progress in the coverage of early antenatal care visits has been achieved but coverage is still far from universal. Substantial inequity exists in coverage both within regions and between income groups. The absence of data in many countries is of concern and efforts should be made to collect and report coverage of early antenatal care visits to enable better monitoring and evaluation.
Influenza epidemiology and immunization during pregnancy: Final report of a World Health Organization working groupby Fell et al
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 outcomeswas 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.
Measuring women’s childbirth experiences: a systematic review for identification and analysis of validated instrumentsby Nilver et al
Women’s childbirth experience can have immediate as well as long-term positive or negative effects on their life, well-being and health. When evaluating and drawing conclusions from research results, women’s experiences of childbirth should be one aspect to consider. Researchers and clinicians need help in finding and selecting the most suitable instrument for their purpose. The aim of this study was therefore to systematically identify and present validated instruments measuring women’s childbirth experience. This systematic review provides an overview of existing instruments measuring women’s childbirth experiences and can support researchers to identify appropriate instruments to be used, and maybe adapted, in their specific contexts and research purpose.
In 2012, the International Federation of Obstetrics and Gynecology (FIGO) produced a chart detailing recommended dosages of misoprostol when used alone, for a variety of obstetric and gynecologic indications. In light of new evidence and through expert deliberation, this chart has now been revised and expanded. The present commentary explain the changes and the decisions made.
The experiences of women with maternal near miss and their perception of quality of care in Kelantan, Malaysia: a qualitative studyby Norhayati et al
Maternal mortality has been the main way of ascertaining the outcome of maternal and obstetric care. However, maternal morbidities occur more frequently than maternal deaths; therefore, maternal near miss was suggested as a more useful indicator for the evaluation and improvement of maternal health services. This study aimed to explore the experiences of women with maternal near miss and their perception of the quality of care in Kelantan, Malaysia. Self-appraisal of maternal near miss, their perception of the quality of care, their predisposition to seek healthcare and the social support received were the four major themes that emerged from the experiences and perceptions of women with maternal near miss. The women with maternal near miss viewed their experiences as frightening and that they experienced other negative emotions and a sense of imminent death. The factors influencing women’s perceptions of quality of care should be of concern to those seeking to improve services at healthcare facilities. The addition of a maternal near miss case review programme, allows for understanding on the factors related to providing care or to the predisposition to seek care; if addressed, may improve future healthcare and patient outcomes.
WHO proposed the WHO Maternal Near Miss (MNM) tool, classifying women according to several (potentially) life-threatening conditions, to monitor and improve quality of obstetric care. The objective of this study is to analyse merged data of one high- and two low-resource settings where this tool was applied and test whether the tool may be suitable for comparing severe maternal outcome (SMO) between these settings. Applying solely organ dysfunction-based criteria may lead to underreporting of SMO. Therefore, a tool based on defining MNM only upon establishing organ failure is of limited use for comparing settings with varying resources. In low-resource settings, lowering the threshold of transfused units of blood leads to a higher detection rate of MNM. We recommend refined disease-based criteria, accompanied by a limited set of intervention- and organ dysfunction-based criteria to set a measure of severity.
A continuous quality improvement intervention to improve the effectiveness of community health workers providing care to mothers and children: a cluster randomised controlled trial in South Africaby Horwood et al
Community health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. This is a cluster randomised controlled trial to investigate the effectiveness of a continuous quality improvement (CQI) intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Findings suggest that improved training and CQI-based mentoring of CHWs can improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers’ knowledge and infant feeding practices.
Quality of antenatal care predicts retention in skilled birth attendance: a multilevel analysis of 28 African countriesby Chukwuma et al
This paper explores predictors of retention of antenatal care clients in skilled birth attendance across Africa, including sociodemographic factors and quality of antenatal care received. Higher quality of ANC predicts retention in SBA in Africa. Improving quality of skilled care received prenatally may increase client retention during delivery, reducing maternal mortality.
Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultationby Bonet et al
There is a need for a clear and actionable definition of maternal sepsis, in order to better assess the burden of this condition, trigger timely and effective treatment and allow comparisons across facilities and countries. The objective of this study was to review maternal sepsis definitions and identification criteria and to report on the results of an expert consultation to develop a new international definition of maternal sepsis. The operationalization of the new maternal sepsis definition requires generation of a set of practical criteria to identify women with sepsis. These criteria should enable clinicians to focus on the timely initiation of actionable elements of care (administration of antimicrobials and fluids, support of vital organ functions, and referral) and improve maternal outcomes.
Defining disrespect and abuse of newborns: a review of the evidence and an expanded typology of respectful maternity careby Sacks E et al
The review revealed examples of mistreatment of newborns in six of the seven categories. Common occurrences were failure to meet a professional standard of care, stigma and discrimination, and health system constraints. Many instances of mistreatment of newborns related to neglect and non-consented care rather than outright physical or verbal abuse. Two additional categories were also identified for newborns related to legal accountability and bereavement care.
This review aims to assess the effects of dietary advice interventions for preventing GDM and associated adverse health outcomes for women and their babies.
The effect of health insurance and health facility-upgrades on hospital deliveries in rural Nigeria: a controlled interrupted time-series studyby Brals et al
Access to quality obstetric care is considered essential to reducing maternal and new-born mortality. The authors evaluated the effect of the introduction of a multifaceted voluntary health insurance programme on hospital deliveries in rural Nigeria. Voluntary health insurance combined with quality healthcare services is highly effective in increasing hospital deliveries in rural Nigeria, by improving access to healthcare for insured and uninsured women in the programme area.
Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysisby Prost et al
This review assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings. With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings.
Summarizes evidence on the impact of community-based programs for improving reproductive, maternal, newborn, and child health (RMNCH) by (1) describing contextual factors affecting implementation; (2) considering issues of cost-effectiveness; and (3) highlighting research gaps, the challenges of scaling up, and the way forward.
Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic reviewby Gilmore et al
This review reports findings on a systematic review analysing effectiveness of preventive interventions delivered by Community Health Workers for Maternal and Child Health in low- and middle-income countries. Community Health Workers were shown to provide a range of preventive interventions for Maternal and Child Health in low- and middle-income countries with some evidence of effective strategies, though insufficient evidence is available to draw conclusions for most interventions and further research is needed.
This themed review brings together NIHR research on different aspects of health before, during and after pregnancy. It features:
- 46 published studies
- 28 ongoing studies or interim results
- Questions for clinicians, commissioners, public health professionals and othe
The effect of a transition into poverty on child and maternal mental health: a longitudinal analysis of the UK Millennium Cohort Studyby Wickham et al
To inform policy, the authors explore the association between transitions into poverty and subsequent mental health among children and their mothers. In a contemporary UK cohort, first transition into income poverty during early childhood was associated with an increase in the risk of child and maternal mental health problems. These effects were independent of changes in employment status. Transitions to income poverty do appear to affect children's life chances and actions that directly reduce income poverty of children are likely to improve child and maternal mental health.
The present study is aimed to explore the association between spontaneous abortion (SA) and socioeconomic status (SES) and provides reference for policy makers to improve strategies on maternal health promotion. Generally women with lower SES status had a higher risk of SA. Lower income and educational attainment were inversely associated with the risk of SA. Women with agricultural and related work had a significantly higher prevalence of SA. Interventions could be targeted more on women with low SES to increase both health profits as well as economic gains for health programs.
In this podcast Dr Jacob McKnight talks about his experiences in neonatal nursing delivery and research in Kenya.
Barriers to accessing adequate maternal care in Central and Eastern European countries: A systematic literature reviewby Miteniece et al
In this study service-related indicators of access to maternal care in CEE are examined. These include availability, appropriateness, affordability, approachability and acceptability of maternal care. Fndings indicate that major gaps in evidence exist and that more representative and better quality data should be collected. Governments in CEE countries need to establish a reliable system for measuring and monitoring a suitable set of indicators, as well as deal with the general social and economic problem of informality. Medical curricula in the CEE region need to be overhauled and there should be a focus on improving the allocation of medical staff and institutions as well as protecting vulnerable population groups to ensure universal access to care.
Effective policymaking to promote the utilization of MHS can be greatly facilitated by the identification of the factors that hinder service uptake. In this study, the authors aim to measure the prevalence of institutional delivery services and explore the factors associated with their utilization in Bangladesh. Results suggest that efforts towards reducing national maternal mortality in Bangladesh could be aided by investments into education, poverty reduction and the strengthening of reproductive healthcare services through community clinics, with particular focus on rural areas.
The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weightby Kiserud et al
WHO made it a high priority to provide the present fetal growth charts for estimated fetal weight (EFW) and common ultrasound biometric measurements intended for worldwide use. This study provides WHO fetal growth charts for EFW and common ultrasound biometric measurements, and shows variation between different parts of the world.
Customised and Noncustomised Birth Weight Centiles and Prediction of Stillbirth and Infant Mortality and Morbidity: A Cohort Study of 979,912 Term Singleton Pregnancies in Scotlandby Iliodromiti et al
This is a population-based linkage study of 979,912 term singleton pregnancies in Scotland, United Kingdom, between 1992 and 2010. At term, birth weight remains strongly associated with the risk of stillbirth and infant death and neonatal morbidity. Partial customisation does not improve prediction performance. Consideration of early term delivery or closer surveillance for those with a predicted birth weight ≤25th or ≥85th centile may reduce adverse outcomes. Replication of the analysis with fully customised centiles accounting for ethnicity is warranted.
Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysisby Popova s et al
Alcohol use during pregnancy is the direct cause of fetal alcohol syndrome (FAS). The authors aimed to estimate the prevalence of alcohol use during pregnancy and FAS in the general population and, by linking these two indicators, estimate the number of pregnant women that consumed alcohol during pregnancy per one case of FAS. Alcohol use during pregnancy is common in many countries and as such, FAS is a relatively prevalent alcohol-related birth defect. More effective prevention strategies targeting alcohol use during pregnancy and surveillance of FAS are urgently needed.
Caesarean section and risk of autism across gestational age: a multi-national cohort study of 5 million birthsby Hon Kei Yip et al
The positive association between caesarean section (CS) and autism spectrum disorder (ASD) may be attributed to preterm delivery. However, due to lack of statistical power, no previous study thoroughly examined this association across gestational age. The authors compared emergency versus planned CS to investigate their potential difference in the risk of ASD using population-based registries of four Nordic countries and Western Australia. Across the five countries, emergency or planned CS is consistently associated with a modest increased risk of ASD from gestational weeks 36 to 42 when compared with vaginal delivery.
Context matters: Successes and challenges of intrapartum care scale-up in four districts of Afghanistanby Tappis et al
This study explores the conditions that affect availability and utilisation of intrapartum care services in four districts of Afghanistan where mortality studies were conducted in 2002 and 2011. Findings suggest that improvements in service coverage must be measured at a sub-national level, and context-specific service delivery models may be needed to effectively scale up intrapartum care services in extremely remote or insecure settings.
The causes of maternal mortality in adolescents in low and middle income countries: a systematic review of the literatureby Neal et al
This study systematically reviews the literature on cause of maternal death in adolescence. Where possible the authors have attempted to compare the main causes for adolescents with those for older women to ascertain differences and similarity in mortality patterns. The main causes of maternal mortality in adolescents are broadly similar to those for older women, although the findings suggest some heterogeneity between countries and regions. However there is evidence that the relative importance of specific causes may differ for this younger age group compared to women over the age of 20 years. In particular hypertensive conditions make up a larger share of maternal deaths in adolescents than older women. Further, large scale studies are needed to investigate this question further.
The Effects of Ghana’s National Health Insurance Scheme on Maternal and Infant Health Care Utilizationby Igna Bonfrer et al
The Ghanaian government implemented the National Health Insurance Scheme in 2004 and the aim of this study is to evaluate its early effects on maternal and infant healthcare use. The authors conclude that in the first years of operation, the National Health Insurance Scheme had a modest impact on the use of antenatal and delivery care. This is important for other African countries currently introducing or considering a national health insurance as a means towards universal health coverage.
Effectiveness of the WHO SCC on improving adherence to essential practices during childbirth, in resource constrained settingsby Kumar et al
In collaboration with the Ministry of Health SCC was modified for Indian context and introduced in 101 intervention facilities in Rajasthan, India and 99 facilities served as comparison to study if it reduces mortality. This Quasi experimental Observational intervention-comparison was embedded in this larger program to test whether a program for introduction of SCC with simple implementation package was associated with increased adherence to 28 evidence-based practices. se of the SCC and provider performance of best practices increased in intervention facilities reflecting improvement in quality of facility childbirth care for women and new-born in low resource settings.
Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015by GBD 2015 Maternal Mortality Collaborators
This study aimed to quantify maternal mortality throughout the world by underlying cause and age from 1990 to 2015. Several challenges to improving reproductive health lie ahead in the SDG era. Countries should establish or renew systems for collection and timely dissemination of health data; expand coverage and improve quality of family planning services, including access to contraception and safe abortion to address high adolescent fertility; invest in improving health system capacity, including coverage of routine reproductive health care and of more advanced obstetric care—including EmOC; adapt health systems and data collection systems to monitor and reverse the increase in indirect, other direct, and late maternal deaths, especially in high SDI locations; and examine their own performance with respect to their SDI level, using that information to formulate strategies to improve performance and ensure optimum reproductive health of their population.
Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countriesby Bizu Gelaye et al
This review is intended to summarise findings from the existing literature, identify important knowledge gaps, and set the research agenda for creating new generalisable knowledge pertinent to increasing our understanding of the prevalence, determinants, and infant and childhood health outcomes associated with perinatal depression. This review is also intended to set the stage for subsequent work aimed at reinforcing and accelerating investments toward providing services to manage maternal depression in low-income and middle-income countries.
Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5?by Moucheraud et al
This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress.
Antenatal corticosteroids are commonly used to reduce neonatal mortality, but most research to date has been in high-resource settings and few studies have evaluated its impact on stillbirth. In the Antenatal Corticosteroids Trial (ACT), a multi-country trial to assess impact of a multi-faceted intervention including antenatal corticosteroids to reduce neonatal mortality associated with preterm birth, we found an overall increase in 28-day neonatal mortality and stillbirth associated with the intervention.
Maternal morbidity associated with violence and maltreatment from husbands and in-laws: findings from Indian slum communitiesby Silverman et al 2016
This study aims to determine the prevalence of non-violent forms of gender-based household maltreatment by husbands and in-laws (GBHM), and violence from in-laws (ILV) and husbands (IPV) against women during the peripregnancy period (during and in the year prior to pregnancy); to assess relative associations of GBHM, ILV and IPV with maternal health. After adjusting for ILV and IPV, peripregnancy GBHM remained significantly associated with multiple forms of maternal morbidity, suggesting that GBHM is a prevalent and reliable indicator of maternal health risk.
Young adolescent girls are at high risk for adverse pregnancy outcomes in sub-Saharan Africa: an observational multicountry studyby Mombo-Ngoma et al
This study assessed whether young adolescent girls constitute a group at increased risk for adverse birth outcomes among pregnant women in sub-Saharan Africa. Young maternal age increases the risk for adverse pregnancy outcomes and it is a stronger predictor for low birth weight and preterm delivery than other established risk factors in sub-Saharan Africa. This finding highlights the need to improve adolescent reproductive health in sub-Saharan Africa.
After the fall of the Taliban in 2001, Afghanistan experienced a tumultuous period of democracy overshadowed by conflict, widespread insurgency, and an inflow of development assistance. Although there have been several cross-sectional assessments of health gains over the last decade, there has been no systematic analysis of progress and factors influencing maternal and child health in Afghanistan. Despite conflict and poverty, Afghanistan has made reasonable progress in its reproductive, maternal, newborn, and child health indicators over the last decade based on contributions of factors within and outside the health sector. However, equitable access to health care remains a challenge and present delivery models have high transactional costs, affecting sustainability.
Reproductive, maternal, newborn, and child health: key messages from Disease Control Priorities 3rd Editionby Black et al
As part of Disease Control Priorities 3rd Edition, the World Bank will publish a volume on Reproductive, Maternal, Newborn, and Child Health that identifies essential cost-effective health interventions that can be scaled up to reduce maternal, newborn, and child deaths, and stillbirths. This Review summarises the volume's key findings and estimates the effect and cost of expanded implementation of these interventions. Recognising that a continuum of care from the adolescent girl, woman, or mother to child is needed, the volume includes details of preventive and therapeutic health interventions in integrated packages: Maternal and Newborn Health and Child Health (along with folic acid supplementation, a key reproductive health intervention).
Development of composite outcomes for individual patient data (IPD) meta-analysis on the effects of diet and lifestyle in pregnancy: a Delphi surveyby Rogozinska et al
The objective of the study was to develop maternal, fetal, and neonatal composite outcomes relevant to the evaluation of diet and lifestyle interventions in pregnancy by individual patient data (IPD) meta-analysis.A two-generational Delphi survey involving members of the i–WIP collaborative network (26 members in 11 countries) was undertaken to prioritise the individual outcomes for their importance in clinical care. The final components of the composite outcomes were identified using pre-specified criteria. The study has identified the components of maternal, fetal, and neonatal composite outcomes required for the assessment of diet and lifestyle interventions in pregnancy by IPD meta-analysis.
Contraceptive use before first pregnancy by women in India (2005–2006): determinants and differentialsby Pandey et al 2015
This study attempts to identify the socio demographic determinants and differentials of contraceptive use or non use by a woman in India, before she proceeds to have her first child. The analysis was done using data from the third National Family Health Survey (2005–2006), India.
Community based reproductive health interventions for young married couples in resource-constrained settings: a systematic reviewby Sarkar et al
This paper presents a review of the available evidence on the effectiveness of community-based health interventions to improve the reproductive health status of young married couples in LMICs. Review suggests that multi-layered community-based interventions, targeting young married women, their families and the health system can improve utilization of reproductive health services among young couples in resource-constrained settings. The paper emphasizes the need for further research to fill the knowledge gaps that exist about improving utilization of reproductive healthcare services, especially safe abortion care among young married women in LMICs.
The EMPOWER Program (EMpowering Progress in Obstetric and Women's hEalth Research) is now accepting research proposals related to preeclampsia and other hypertensive disorders of pregnancy from young investigators in low resource settings. Letters of Intent are due November 15, 2015. Thereafter, projects deemed feasible will be invited to submit full applications by April 15, 2016. The grant recipient will be announced in October 2016 at the World Congress of the International Society for the Study of Hypertension in Pregnancy (ISSHP).
Economic interventions are increasingly recognised as a mechanism to address perinatal health outcomes among disadvantaged groups. In the US, the earned income tax credit (EITC) is the largest poverty alleviation programme. Little is known about its effects on perinatal health among recipients and their children. The authors exploit quasi-random variation in the size of EITC payments to examine the effects of income on perinatal health. Findings suggest that EITC payment size is associated with better levels of several indicators of perinatal health. Instrumental variables analysis, however, does not reveal a causal association between household income and these health measures.
Association between maternal age at childbirth and child and adult outcomes in the off spring: a prospective study in fi ve low-income and middle-income countries (COHORTS collaboration)by Fall et al
The study aimes to assess both child and adult outcomes in five LMICs. Children of young mothers in LMICs are disadvantaged at birth and in childhood nutrition and schooling. Efforts to prevent early childbearing should be strengthened. After adjustment for confounders, children of older mothers have advantages in nutritional status and schooling. Extremes of maternal age could be associated with disturbed off spring glucose metabolism.
Does the type of abortion provider influence contraceptive uptake after abortion? An analysis of longitudinal data from 64 health facilities in Ghanaby Maxwell et al
The objectives of this study were to estimate the relationship between the type of abortion provider (consultant physician, house officer, or midwife) and two separate outcomes: (1) the likelihood of adopting postabortion contraception; (2) postabortion contraceptors’ likelihood of receiving a long-acting and permanent versus a short-acting contraceptive method.
Dr Nat Segaren - Medical Director of the Caris Foundation, presents on 'The Haiti National Early Infant Diagnosis of HIV Program'
Determinants of unmet need for family planning among currently married women in Dangila town administration, Awi Zone, Amhara regional state; a cross sectional studyby Genet et al
Evidences about unmet need for family planning and associated factors are not enough in Dangila town. Therefore, this study was done to assess the magnitude and determinants of unmet need for family planning among currently married women in Dangila town. Findings suggest that the level of unmet need for family planning in the study area is still high compared to the target set (10 %) in the national family planning guide plan of Ethiopia to be achieved by the end of 2015. Therefore, it is important to strengthen counseling and partner involvement in Dangila town to reduce unmet need for family planning.
Birth preparedness and complication readiness among recently delivered women in chamwino district, central Tanzania: a cross sectional studyby Bintabara et al
Birth Preparedness and Complication Readiness is among the key interventions that can reduce maternal mortality. Despite this, its status in Tanzania is not well documented. The authors assessed the practice and determinants of Birth preparedness and complication readiness among recently delivered women in Chamwino district, Central Tanzania. Findings suggest that the proportion of women who prepared for birth and its complications were found to be low. District reproductive and child health coordinator should emphasis on early and frequent antenatal care visits, since they were among predictors of birth preparedness and complication readiness.
Between-hospital variation in outcomes among extremely preterm infants is largely unexplained and may reflect differences in hospital practices regarding the initiation of active lifesaving treatment as compared with comfort care after birth. Differences in hospital practices regarding the initiation of active treatment in infants born at 22, 23, or 24 weeks of gestation explain some of the between-hospital variation in survival and survival without impairment among such patients.
In celebration of Global Health Trials' fifth birthday (May 11th 2015) Professor Trudie Lang, Principal Investigator of the programme, talks to us about why Global Health Trials was started, why people should share their experience, and what the future holds.
A review of e-health interventions for maternal and child health (MCH) to explore their influence on MCH practices in sub-Sahara Africa found a total of 18 relevant articles. Findings suggeswt that there is a need to move the application of ICT for MCH care from pilot initiatives to interventions involving all stakeholders on a sub-regional scale. These interventions should also adopt an integrated approach that takes care of the information needs at every stage along the continuum of care. It is anticipated that the study would be useful in the evolution and implementation of future ICT-based programmes for MCH in the region.
Levels, trends and reasons for unmet need for family planning among married women in Botswana: a cross-sectional studyby Letamo et al
The objectives of this study were to estimate the prevalence of unmet need for family planning among married women using Botswana Family Health Survey 2007 data and to identify risk factors for unmet need for family planning among married women.Findings suggest that the prevalence of unmet need for family planning was low in Botswana compared to other sub-Saharan African countries. The findings from this study reemphasise the importance of women's empowerment and men's involvement in women's sexual and reproductive healthcare needs and services. Different approaches are needed to satisfy the demand for family planning for spacing and limiting.
Smoking in pregnancy is known to be associated with a range of adverse pregnancy outcomes, yet there is a high prevalence of smoking among pregnant women in many countries, and it remains a major public health concern. The authors have conducted a systematic review and meta-analysis to provide contemporary estimates of the association between maternal smoking in pregnancy and the risk of stillbirth. The review findings confirm a dose-response effect of maternal smoking in pregnancy on risk of stillbirth. To minimise the risk of stillbirth, reducing current smoking prevalence in pregnancy should continue to be a key public health high priority.
Rubella remains an important pathogen worldwide, with roughly 100 000 cases of congenital rubella syndrome estimated to occur every year. This seminar present results regarding rubella control, elimination, and eradication policies, and a brief review of new laboratory diagnostics.
Maternal and perinatal health research priorities beyond 2015: an international survey and prioritization exerciseby Souza JP et al
Maternal mortality has declined by nearly half since 1990, but over a quarter million women still die every year of causes related to pregnancy and childbirth. Maternal-health related targets are falling short of the 2015 Millennium Development Goals and a post-2015 Development Agenda is emerging. In connection with this, setting global research priorities for the next decade is now required. The authors in this paper adapted the methods of the Child Health and Nutrition Research Initiative (CHNRI) to identify and set global research priorities for maternal and perinatal health for the period 2015 to 2025.
Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Databaseby Kozhimannil et al
The authors in this study used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses. Findings suggest that variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses.
Intermittent Preventive Treatment of Malaria in Pregnancy with Mefloquine in HIV-Negative Women: A Multicentre Randomized Controlled Trialby González et al
Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended by WHO to prevent malaria in African pregnant women. The spread of SP parasite resistance has raised concerns regarding long-term use for IPT. Mefloquine (MQ) is the most promising of available alternatives to SP based on safety profile, long half-life, and high efficacy in Africa. This study evaluated the safety and efficacy of MQ for IPTp compared to those of SP in HIV-negative women. Women taking MQ IPTp (15 mg/kg) in the context of long lasting insecticide treated nets had similar prevalence rates of low birth weight as those taking SP IPTp. MQ recipients had less clinical malaria than SP recipients, and the pregnancy outcomes and safety profile were similar. MQ had poorer tolerability even when splitting the dose over two days. These results do not support a change in the current IPTp policy.
Breastfeeding Progression in Preterm Infants Is Influenced by Factors in Infants, Mothers and Clinical Practice: The Results of a National Cohort Study with High Breastfeeding Initiation Ratesby Maastrup et al
Many preterm infants are not capable of exclusive breastfeeding from birth. To guide mothers in breastfeeding, it is important to know when preterm infants can initiate breastfeeding and progress. The aim of this study was to analyse postmenstrual age at breastfeeding milestones in different preterm gestational age groups, to describe rates of breastfeeding duration at pre-defined times, as well as analyse factors associated with PMA at the establishment of exclusive breastfeeding. The study concludes that breastfeeding competence is not developed at a fixed postmenstrual age, but is influenced by multiple factors in infants, mothers and clinical practice. Admitting mothers together with their infants to the NICU and minimising the use of pacifiers may contribute to earlier establishment of exclusive breastfeeding.
This series of five papers assesses and summarizes information from relevant systematic reviews on the impact of various approaches to improve the quality of care for women and newborns.
Use of antenatal corticosteroids and tocolytic drugs in preterm births in 29 countries: an analysis of the WHO Multicountry Survey on Maternal and Newborn Healthby Vogel JP et al
Despite the global burden of morbidity and mortality associated with preterm birth, little evidence is available for use of antenatal corticosteroids and tocolytic drugs in preterm births in low-income and middle-income countries. The authors in thsi study analysed data from the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS) to assess coverage for these interventions in preterm deliveries. Use of interventions was generally poor, despite evidence for their benefit for newborn babies. A substantial proportion of antenatal corticosteroid use occurred at gestational ages at which benefit is controversial, and use of less effective or potentially harmful tocolytic drugs was common. Implementation research and contextualised health policies are needed to improve drug availability and increase compliance with best obstetric practice.
Worldwide, 250,000–280,000 women die during pregnancy and childbirth every year and an estimated 6.55 million children die under the age of five. The majority of maternal deaths occur during or immediately after childbirth, while 43% of child death occurs during the first 28 days of life. However, the progress in limiting these has been slow and sporadic. In this supplement of five papers, teh authors aim to systematically assess and summarize essential interventions for reproductive, maternal, newborn and child health from relevant systematic reviews.
Intrauterine growth restriction (IUGR) is responsible for the higher rates of fetal, perinatal, and neonatal morbidity and mortality. This review details the IUGR risk factors, its short and long-term sequel, themechanism underlying the long-term consequences, and the strategies to tackle IUGR burden.
Cesarean Section and Rate of Subsequent Stillbirth, Miscarriage, and Ectopic Pregnancy: A Danish Register-Based Cohort Studyby Jai K Das
With cesarean section rates increasing worldwide, clarity regarding negative effects is essential. This study aimed to investigate the rate of subsequent stillbirth, miscarriage, and ectopic pregnancy following primary cesarean section, controlling for confounding by indication. This study found that cesarean section is associated with a small increased rate of subsequent stillbirth and ectopic pregnancy. Underlying medical conditions, however, and confounding by indication for the primary cesarean delivery account for at least part of this increased rate. These findings will assist women and health-care providers to reach more informed decisions regarding mode of delivery.
Maternal Overweight and Obesity and Risks of Severe Birth-Asphyxia-Related Complications in Term Infants: A Population-Based Cohort Study in Swedenby Jai K Das
Maternal overweight and obesity increase risks of pregnancy and delivery complications and neonatal mortality, but the mechanisms are unclear. The objective of this study was to investigate associations between maternal body mass index (BMI) in early pregnancy and severe asphyxia-related outcomes in infants delivered at term (≥37 weeks).
Food fortification is safe and cost-effective in the prevention of micronutrient deficiencies and has been widely practiced in developed countries for well over a century. The findings in this report clearly support the utilization of food fortification strategies at scale, which could build on the recent success of the iodized salt programme. Given the widespread prevalence in Pakistan of deficiencies in iron and in vitamins A and D, food fortification strategies offer a tangible option for delivering these micronutrients on a large scale.
Rates and determinants of seasonal influenza vaccination in pregnancy and association with neonatal outcomesby Jai K Das
There is growing evidence that seasonal influenza vaccination in pregnancy has benefits for mother and baby. The authors in this paper determined influenza vaccination rates among pregnant women during the 2 nonpandemic influenza seasons following the 2009 H1N1 pandemic, explored maternal factors as predictors of influenza vaccination status and evaluated the association between maternal influenza vaccination and neonatal outcomes. This study and others have shown an association between maternal influenza vaccination and improved neonatal outcomes, which supports stronger initiatives to promote vaccination during pregnancy.
Stillbirth is strongly related to impaired fetal growth. However, the relationship between fetal growth and stillbirth is difficult to determine because of uncertainty in the timing of death and confounding characteristics affecting normal fetal growth. The study authors conducted a population-based case–control study of all stillbirths and a representative sample of live births in 59 hospitals in five geographic areas in the US. The study found that stillbirth is associated with both growth restriction and excessive fetal growth. These findings suggest that, contrary to current practices and recommendations, stillbirth prevention strategies should focus on both severe SGA and severe LGA pregnancies.
Effect of gravity on volume of placental transfusion: a multicentre, randomised, non-inferiority trialby Jai K Das
Delayed cord clamping allows for the passage of blood from the placenta to the baby and reduces the risk of iron deficiency in infancy. To hold the infant for more than 1 min at the level of the vagina (as is presently recommended), on the assumption that gravity affects the volume of placental transfusion, is cumbersome, might result in low compliance, and interferes with immediate contact of the infant with the mother. This study aimed to assess whether gravity affects the volume of placental transfusion.
Can food vouchers improve nutrition and reduce health inequalities in low-income mothers and young children: a multi-method evaluationby Jai K Das
Good nutrition is important during pregnancy, breastfeeding and early life to optimise the health of women and children. It is difficult for low-income families to prioritise spending on healthy food. Healthy Start is a targeted United Kingdom (UK) food subsidy programme that gives vouchers for fruit, vegetables, milk, and vitamins to low-income families. This paper reports an evaluation of Healthy Start from the perspectives of women and health practitioners.
In 2013, the WHO released a new set of guidelines on the prevention of mother to child transmission (PMTCT) of HIV/AIDS. The new guidelines suggests that all pregnant women who test positive for HIV should immediately begin a course of triple ARVs, regardless of CD4 cell levels.
A Risk Prediction Model for the Assessment and Triage of Women with Hypertensive Disorders of Pregnancy in Low-Resourced Settings: The miniPIERS Multi-country Prospective Cohort Studyby Jai K Das
Pre-eclampsia/eclampsia are leading causes of maternal mortality and morbidity, particularly in low- and middle- income countries (LMICs). The authors developed the miniPIERS risk prediction model to provide a simple, evidence-based tool to identify pregnant women in LMICs at increased risk of death or major hypertensive-related complications.
Moleen Zunza is a member of the Global Research Nurses' network and is part of the team that has published this systematic review.
Though many countries are on-track in reducing poverty, less than a quarter of developing countries are on-track for achieving the goal of halving undernutrition. Maternal undernutrition is widely prevalent among women in the developing countries and encompasses both chronic energy as well as micronutrient deficiencies. Maternal undernutrition leads to intrauterine growth restriction and consequent low birth weight, stunting, wasting, underweight and other micronutrient deficiencies along with conditions predisposing to mortality. There are no effective therapies to reverse intrauterine growth restriction; hence focus should be on preventive strategies. In developing countries, the interventions likely to have the largest impact on intrauterine growth include caloric and micronutrient supplementation before and during pregnancy, coupled with supportive strategies for improving nutrition.
Antenatal Syphilis Screening Using Point-of-Care Testing in Sub-Saharan African Countries: A Cost-Effectiveness Analysisby Jai K Das
The objective of this analysis was to evaluate the cost-effectiveness and budget impact of antenatal syphilis screening for 43 countries in SSA and estimate the impact of universal screening on stillbirths, neonatal deaths, congenital syphilis, and disability-adjusted life years (DALYs) averted.
Psychosocial Interventions for Perinatal Common Mental Disorders Delivered by Providers Who Are Not Mental Health Specialists in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysisby Jai K Das
Perinatal common mental disorders (PCMDs) are a major cause of disability among women. Psychosocial interventions are one approach to reduce the burden of PCMDs. Working with care providers who are not mental health specialists, in the community or in antenatal health care facilities, can expand access to these interventions in low-resource settings. The authors in this study assessed effects of such interventions compared to usual perinatal care, as well as effects of interventions based on intervention type, delivery method, and timing.
Effect on Postpartum Hemorrhage of Prophylactic Oxytocin (10 IU) by Injection by Community Health Officers in Ghana: A Community-Based, Cluster-Randomized Trialby Jai K Das
Oxytocin is the drug of choice for prevention of postpartum hemorrhage. Its use has generally been restricted to medically trained staff in health facilities. The authors in this paper assessed the effectiveness, safety, and feasibility of PPH prevention using oxytocin injected by peripheral health care providers without midwifery skills at home births.
This systematic review of the current evidence assessed the effectiveness of food fortification with single micronutrients (iron, folic acid, vitamin A, vitamin D, iodine, zinc) as well as MMN when compared with no fortification on the health and nutrition of women and children.
The Effect of Intermittent Antenatal Iron Supplementation on Maternal and Infant Outcomes in Rural Viet Nam: A Cluster Randomised Trialby Jai K Das
Anemia affects over 500 million women, and in pregnancy is associated with impaired maternal and infant outcomes. Intermittent antenatal iron supplementation is an attractive alternative to daily dosing; however, the impact of this strategy on infant outcomes remains unclear. This study compared the effect of intermittent antenatal iron supplementation with daily iron supplementation on maternal and infant outcomes in rural Viet Nam.
Effect of Facilitation of Local Maternal-and-Newborn Stakeholder Groups on Neonatal Mortality: Cluster-Randomized Controlled Trialby Jai K Das
Facilitation of local women's groups may reportedly reduce neonatal mortality. It is not known whether facilitation of groups composed of local health care staff and politicians can improve perinatal outcomes. This study hypothesised that facilitation of local stakeholder groups would reduce neonatal mortality (primary outcome) and improve maternal, delivery, and newborn care indicators (secondary outcomes) in Quang Ninh province, Vietnam.
Risk of Early-Onset Neonatal Infection with Maternal Infection or Colonization: A Global Systematic Review and Meta-Analysisby Jai K Das
Neonatal infections cause a significant proportion of deaths in the first week of life, yet little is known about risk factors and pathways of transmission for early-onset neonatal sepsis globally. This review aimed to estimate the risk of neonatal infection (excluding sexually transmitted diseases [STDs] or congenital infections) in the first seven days of life among newborns of mothers with bacterial infection or colonization during the intrapartum period.
India, with a population of more than 1.21 billion, has the highest maternal mortality in the world (estimated to be 56000 in 2010); and adolescent (aged 15–19) mortality shares 9% of total maternal deaths. Addressing the maternity care needs of adolescents may have considerable ramifications for achieving the Millennium Development Goal (MDG)–5. This paper assesses the socioeconomic differentials in accessing full antenatal care and professional attendance at delivery by adolescent mothers (aged 15–19) in India during 1990–2006.
The authors propose four arguments for why cervical cancer screening and treatment should be included when it comes to operationalizing these two goals and thus to improving reproductive and maternal health outcomes. Each of the four arguments is illustrative of a larger framework that has equity and socioeconomic, gender, public health, and health services dimensions.
Factors Affecting the Delivery, Access, and Use of Interventions to Prevent Malaria in Pregnancy in Sub-Saharan Africa: A Systematic Review and Meta-Analysisby Jai K Das
Malaria in pregnancy has important consequences for mother and baby. Coverage with the World Health Organization–recommended prevention strategy for pregnant women in sub-Saharan Africa of intermittent preventive treatment in pregnancy (IPTp) and insecticide-treated nets (ITNs) is low. This systematic review explores factors affecting delivery, access, and use of IPTp and ITNs among healthcare providers and women
Recent research has established linkages of preconception interventions with improved maternal, perinatal and neonatal health outcomes and it has been suggested that several proven interventions recommended during pregnancy may be even more effective if implemented before conception. The authors in this report have collated and synthesized relevant information on interventions available during the preconception period by using standard methods.
The Effect of Intermittent Antenatal Iron Supplementation on Maternal and Infant Outcomes in Rural Viet Nam: A Cluster Randomised Trialby Jai K Das
Intermittent antenatal iron supplementation is an attractive alternative to daily dosing; however, the impact of this strategy on infant outcomes remains unclear. This study compared the effect of intermittent antenatal iron supplementation with daily iron supplementation on maternal and infant outcomes in rural Viet Nam.
This study suggests that to achieve a substantial reduction in maternal mortality, a comprehensive approach to emergency care, and overall improvements in the quality of maternal health care will be needed.
Changes in Association between Previous Therapeutic Abortion and Preterm Birth in Scotland, 1980 to 2008: A Historical Cohort Studyby Jai K Das
The authors in this study hypothesized that the association between previous abortion and the risk of preterm first birth changed in Scotland between 1 January 1980 and 31 December 2008.
Little is known about factors contributing to inequities in antenatal care use in Ethiopia. This study aimed to assess inequities in the use of antenatal care on the basis of area of residence, administrative region, economic status and education.
Integrating maternal mental health care will help advance maternal and child health (MCH) status. This paper is the second in a series of five articles providing a global perspective on integrating mental health.
Malnutrition still remains one of the major public health challenges, particularly in developing countries. Major risk factors for undernutrition such as suboptimal breastfeeding and micronutrient deficiencies (vitamin A and zinc) are responsible for more than one-third of all under five child deaths and 11% of the global total disease burden. Several strategies have been employed to supplement micronutrients. These include education, dietary modification, food provision, supplementation and fortification either alone or in combination.
Maternal and child undernutrition Series was launched in The Lancet in 2008. Five years after the initial series, the issue was re-evaluated including the growing problems of overweight and obesity for women and children, and their consequences in low-income and middle-income countries. Many of these countries are said to have the double burden of malnutrition: continued stunting of growth and deficiencies of essential nutrients along with the emerging issue of obesity. The national progress in nutrition programmes and international efforts toward previous recommendations were also evaluated
The Lancet publishes a special themed issue to coincide with the third Women Deliver conference in Kuala Lumpur, Malaysia on May 28–30, 2013. Women Deliver brings together voices from around the world to generate political commitment and resource investments to improve the health and well-being of girls and women and achieve universal access to reproductive health. The studies published in The Lancet's themed issue use different methods to show the multidimensional nature of reproductive health and the influence of social determinants and health systems.
The PLOS Medicine “Measuring Coverage in MNCH” Collection of research studies and reviews presents systematic assessments of the validity of health intervention coverage measurement based on household surveys, the primary method for estimating population-level intervention coverage in low- and middle-income countries. This is the first paper of the collection
Over the last decade, a number of influential organisations have called for the integration of mental, neurological and substance use (MNS) disorders into large scale public health programmes. Although progress at the implementation level has been slow, the development of a number of evidence-based, potentially scalable interventions in the MNS field provides new impetus to develop strategies for integration with broader programmes. Integrating maternal mental health care will help advance maternal and child health (MCH) status.
e have recently added a Canadian cohort study from PLOS Medicine providing valuable new evidence on preeclampsia (PEC) and the impetus for discussing whether it is now time to consider screening women with a history of hypertensive pregnancy disorders. This paper discusses the feasibility of systematic screening of women with a history of Hypertensive Pregnancyand its mangement.
Women with preeclampsia (PEC) and gestational hypertension (GH) exhibit insulin resistance during pregnancy, independent of obesity and glucose intolerance. The authors in this paper aim to determine whether women with PEC or GH during pregnancy have an increased risk of developing diabetes after pregnancy, and whether the presence of PEC/GH in addition to gestational diabetes (GDM) increases the risk of future (postpartum) diabetes.
Young Children's Probability of Dying Before and After Their Mother's Death: A Rural South African Population-Based Surveillance Studyby Jai K Das
There is evidence that a young child's risk of dying increases following the mother's death, but little is known about the risk when the mother becomes very ill prior to her death. We hypothesized that children would be more likely to die during the period several months before their mother's death, as well as for several months after her death. Therefore the authors in this paper investigated the relationship between young children's likelihood of dying and the timing of their mother's death and, in particular, the existence of a critical period of increased risk.
Why Do Women Not Use Antenatal Services in Low- and Middle-Income Countries? A Meta-Synthesis of Qualitative Studiesby Jai K Das
This study informs the development of future antenatal care programmes through a synthesis of findings in all relevant qualitative studies.
It is estimated that 41.8% of pregnant women worldwide are anaemic. Approximately 60% of these cases in non-malarious areas, and 50% in malaria-endemic settings, are assumed to be due to iron deficiency. We share the WHO guideline providing global, evidence-informed recommendations on the use of multiple micronutrient powders for home fortification of foods consumed by pregnant women.
The use of mobile phones has grown exponentially in the last decade including in some of the most remote and low-resource regions of the world. The use of mobile technology in health care is known as mHealth. mHealth interventions are being used internationally to improve maternal and child health. Be it the use of a mobile phone to call for emergency transport, remote consultation, or large-scale short message service (SMS)-based community education programs, mHealth is demonstrating its utility in reproductive health programs throughout the world. This article describes the evolution and challenges of mHealth, discusses the role of mHealth in achieving Millennium Development Goals 4 and 5, and addresses the potential impact of mHealth for midwives
Global Estimates of Syphilis in Pregnancy and Associated Adverse Outcomes: Analysis of Multinational Antenatal Surveillance Databy Jai K Das
Syphilis continues to affect large numbers of pregnant women, causing substantial perinatal morbidity and mortality that could be prevented by early testing and treatment. The authors in the attached paper calculated global and regional estimates of syphilis in pregnancy and associated adverse outcomes for 2008, as well as antenatal care (ANC) coverage for women with syphilis.
The universal coverage with the full package of these proven interventions at observed levels of program effectiveness could prevent about one quarter of child deaths under 36 months of age and reduce the prevalence of stunting at 36 months by about one third. I attach my recent review on the possible strategies to combat malnutrition include promotion of breastfeeding, dietary supplementation of micronutrients, prevention of protein-energy malnutrition, and hygiene of available weaning foods and how best topackage these intevrentions for universal scale-up.
In response to the unacceptable maternal health situation, WHO has developed the Pilot Edition of the Safe Childbirth Checklist, to support the delivery of essential maternal and perinatal care practices. The WHO Safe Childbirth Checklist contains 29 items addressing the major causes of maternal death (namely, haemorrhage, infection, obstructed labour and hypertensive disorders), intrapartum-related stillbirths (namely, inadequate intrapartum care), and neonatal deaths (namely birth asphyxia, infection and complications related to prematurity) in low-income countries. It was developed following a rigorous methodology and tested for usability in ten countries across Africa and Asia. Please have a look at the below link:
WHO proposes a set of organ-failure based criteria for maternal near miss. The objective was to evaluate what implementation of these criteria would mean for the analysis of a cohort of 386 women in Thyolo District, Malawi, who sustained severe acute maternal morbidity according to disease-based criteria.
Translating Coverage Gains into Health Gains for All Women and Children: The Quality Care Opportunityby Jai K Das
The health outcomes of women and children have not matched expectations from the gains in the coverage of care. Robust evidence exists for one explanatory factor: the poor–rich gaps in coverage found along the continuum of care for women and children, and particularly for the crucial period around childbirth. The more-neglected explanation for the mismatch between coverage and health outcomes is the quality of the care provided to women and children. The following paper is structured around a key cause and a consequence of the neglect of quality—weak measurement and poor evidence for action—and concludes with priorities for seizing the quality care opportunity.
Women of reproductive age are at increased risk of anaemia because of chronic iron depletion during the menstrual cycle. It is estimated that worldwide there are 469 million anaemic women of reproductive age. At least half of the cases are attributed to iron deficiency. We share the WHO guidleines for Intermittent iron and folic acid supplementation in menstruating women.
Maternal, newborn, and child health indices in Nigeria vary widely across geopolitical zones and between urban and rural areas, mostly due to variations in the availability of skilled attendance at birth. To improve these indices, the Midwives Service Scheme (MSS) in Nigeria engaged newly graduated, unemployed, and retired midwives to work temporarily in rural areas. This paper describes the structure, processes, challanges and the outcomes acheived through MSS.
Comprehensive Approach to Improving Maternal Health and Achieving MDG 5: Report from the Mountains of Lesothoby Jai K Das
The emerging consensus is that improvement in women's health cannot be made through simple, vertical strategies; rather, it requires broad-based health system strengthening at every level of care, from the community to the clinic to the hospital. This paper reports experience in rural Lesotho, where a pilot program was implemented that provided comprehensive care of pregnant women from the community to the health center level, linking key primary care services (include HIV testing and treatment) to antenatal care (ANC) and facility-based delivery.
Antenatal care (ANC) provides a crucial opportunity to reach high risk women and prevent pregnancy related complications and the consequent mortalities. We share a study conducted in Zambia that evaluates the role health service factors. The study objective was to assess how distance to facilities and level of service provision at ANC facilities in Zambia influenced the number and timing of ANC visits and the quality of care received.
Among the hypertensive disorders that complicate pregnancy, pre-eclampsia and eclampsia stand out as major causes of maternal and perinatal mortality and morbidity. The majority of deaths due to pre-eclampsia and eclampsia are avoidable through the provision of timely and effective care to the women presenting with these complications.We share the recent WHO guidelines for the prevention and management of Pre-Eclampsia/Eclampsia
Post Partum Haemorrhage (PPH) is generally defined as blood loss greater than or equal to 500 ml within 24 hours after birth, while severe PPH is blood loss greater than or equal to 1000 ml within 24 hours. PPH is the most common cause of maternal death worldwide. We share the WHO guidelines for the mangement of PPH. It recommends that active management at the third stage of labour should include: (i) administration of a uterotonic soon after the birth of the baby; (ii) clamping of the cord following the observation of uterine contraction (at around 3 minutes); and (iii) delivery of the placenta by controlled cord traction, followed by uterine massage.
Comparing HIV prevalence estimates from prevention of mother-to-child HIV transmission programme and the antenatal HIV surveillance in Addis Abababy Jai K Das
Currently multiple vertical and integrated programs are running concurrently to provide estimates for HIV prevalances in epidemic areas. These programs require careful evaluations and comparisons.This study was conducted in Addis Ababa to compare HIV prevalence estimates from routine PMTCT programme and antenatal surveillance with the aim to come up with evidence based recommendation.
Addressing inequity to achieve the maternal and child health millennium development goals: looking beyond averagesby Jai K Das
Inequity in access to and use of child and maternal health interventions is impeding progress towards the maternal and child health Millennium Development Goals. This study explores the potential health gains and equity impact if a set of priority interventions for mothers and under fives were scaled up to reach national universal coverage targets for MDGs in Tanzania.
Repository on maternal child health: Health portal to improve access to information on maternal child health in Indiaby Jai K Das
This article describes a health portal developed in India aimed at providing one-stop access to efficiently search, organize and share maternal child health information relevant from public health perspective in the country.
New Signal Functions to Measure the Ability of Health Facilities to Provide Routine and Emergency Newborn Careby Jai K Das
Emergency obstetric care (EmOC) signal functions, reflecting health facilities' capacity to respond to important obstetric complications, are widely used to construct indicators of service provision. However, no signal functions are agreed for emergency newborn care (EmNC), except newborn resuscitation, or for routine non-emergency care for mothers and newborns.
Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Healthby Jai K Das
Serious and Life-Threatening Pregnancy-Related Infections: Opportunities to Reduce the Global Burdenby Courtney A. Gravett
This Policy Forum article aims to highlight opportunities for screening and appropriate treatment of life-threatening pregnancy-related interventions.
The attached report by World Health Organization and UNICEF reports that Maternal mortality has declined dramatically, but faster progress is needed. The report further highlights geographical disparaties in maternal, newborn and child survival.