Research Round-Up: February 2011

Anaemia and Stillbirth in Kassala Hospital, Eastern Sudan. AA Aziem Ali, I Adam. Journal of Tropical Pediatrics, 57 (1): 62-64, 2011.

Background: Globally, the reduction of stillbirths is a high priority, especially in view of the targets set by the Millennium Development Goals. It is crucial that health policy-makers and programme managers are aware of the epidemiology of stillbirths. Objectives: This was a case–control study conducted in Kassala hospital in Eastern Sudan to investigate the prevalence and risk factors for stillbirth. Cases were women who delivered stillbirths; two consecutive women who delivered a live-born neonate per case were used as controls. Results: Among 1342 singleton deliveries, there were 44 stillbirths (33 per 1000 deliveries). Over half (54.5%) of these stillbirths were macerated stillbirths. While maternal socio-demographic characteristics were not associated with stillbirth, maternal anaemia was the main risk factor for stillbirth (Odds ratio = 8.4, 95% CI = 2.5–29.4; P = 0.001). Conclusion: Thus, greater focus on maternal nutrition and prevention of anaemia may prevent stillbirth in this setting.

Antenatal education for expectant mothers results in sustained improvement in knowledge of newborn care*. EA Weiner, S Billamay, JC Partridge, AM Martinez. Journal of Perinatology, 31, 92–97; February 2011.

Objective: Basic perinatal education to increase parental knowledge of neonatal illnesses (such as respiratory distress, sepsis, complications of prematurity) could be a feasible way to reduce high neonatal mortality rates in limited-resource nurseries. To assess the efficacy of antenatal education in increasing mothers’ knowledge of basic newborn care in a limited-resource nursery, and to determine whether the knowledge is retained postpartum. Study Design: In March to April 2008, we implemented a 10-min educational program on basic neonatal care for women receiving prenatal care in a maternal child hospital in Vientiane, Laos. The educational intervention was a structured, face-to-face interactive module taught by Lao providers using pictographic and written materials about temperature control, umbilical cord care and signs of neonatal illness. We assessed knowledge before and immediately after the module using a standardized interview tool. When possible, we reassessed knowledge postpartum to determine whether they retained information after the training. Result: We recruited 101 women (average age=26.3 years), and the majority (53%) were primigravidas. Participants were well educated by local standards; 57% of women had >8 years and 28% had >12 years of education. Women's knowledge of neonatal care increased by 10% on immediate posttest (P<0.0001), especially regarding knowledge of umbilical cord care and temperature control (normal temperature ranges, thermometer use). Maternal education (P=0.025) and previous births (P=0.037) correlated positively with higher pretest scores. Higher maternal education correlated with higher posttest scores (P=0.01); however, less-educated women increased their scores as much as did women with more education. Nulliparous women also increased their posttest scores to comparable levels in women with previous deliveries. Women retested after delivery retained the educational message, achieving similar posttest and postdelivery scores (P=0.08). Conclusion: Brief antenatal education increases mothers’ understanding of basic newborn care. Mothers retain this knowledge into the early postpartum period and during early infancy when it might help reduce morbidity and mortality. The education was efficacious for women with little education. Brief antenatal educational modules seem a feasible, sustainable means of improving mothers’ knowledge of newborn care. We speculate that similar programs could improve neonatal morbidity and mortality in developing countries.

Clinical outcomes of the first midwife-led normal birth unit in China: a retrospective cohort study*. NF Cheung, R Mander, et al. Midwifery, In Press.

Aims: to report the clinical outcomes of the first six months of operation of an innovative midwife-led normal birth unit (MNBU) in China in 2008, aiming to facilitate normal birth and enhance midwifery practice. Setting: an urban hospital with 2000-3000 deliveries per year. Method: this study was part of a major action research project that led to implementation of the MNBU. A retrospective cohort and a questionnaire survey were used. The data were analysed thematically. Participants: the outcomes of the first 226 women accessing the MNBU were compared with a matched retrospective cohort of 226 women accessing standard care. In total, 128 participants completed a satisfaction questionnaire before discharge. Main outcome measure: mode of birth and model of care. Findings: the vaginal birth rate was 87.6% in the MNBU compared with 58.8% in the standard care unit. All women who accessed the MNBU were supported by both a midwife and a birth companion, referred to as [`]two-to-one' care. None of the women labouring in the standard care unit were identified as having a birth companion. Discussion: the concept of [`]two-to-one' care emerged as fundamental to women's experiences and utilisation of midwives' skills to promote normal birth and decrease the likelihood of a caesarean section. Conclusion: the MNBU provides an environment where midwives can practice to the full extent of their role. The high vaginal birth rate in the MNBU indicates the potential of this model of care to reduce obstetric intervention and increase women's satisfaction with care within a context of extraordinary high caesarean section rates. Implications for practice: midwife-led care implies a separation of obstetric care from maternity care, which has been advocated in many European countries.

Determinants of perinatal mortality in Marondera district, Mashonaland East Province of Zimbabwe, 2009: a case control study. T Emmanuel, G Notion, S Gerald, et al. The Pan African Medical Journal; 8:7, February 2011.

Background: Marondera District recorded perinatal mortality ratios of 58.6/1000 and 64.6/1000 live births in 2007 and 2008 respectively. These ratios were above provincial averages of 32/1000 and 36/1000 during the same periods. We determined factors associated with perinatal mortality in Marondera District, Zimbabwe. Methods: A 1:2 unmatched case control study was carried out from June to August 2009. A  case was any mother in Marondera District who had a stillbirth or early neonatal death from 01/08/2008 to 31/07/2009. A control was any mother whose baby survived the perinatal period during the same period. We calculated Odds Ratios and their 95% confidence intervals. Results: We interviewed 103 cases and 206 controls. Primary or no maternal education [OR=5.50 (3.14-9.33)] labor complications [OR=7.56 (4.38-13.06)], home delivery [OR=7.38 (4.03-13.68)] and preterm delivery [OR=15.06 (8.24-27.54)] increased the risk for perinatal mortality. Antenatal care booking [OR=0.19 (0.10-0.34)], having a gainfully employed husband [OR=0.36 (0.20-0.63)] and living within 5km of a health facility [OR=0.41 (0.22-0.78)] reduced the risk. Independent determinants of perinatal mortality included being apostolic [AOR=3.11 (1.05-9.18)], having a home delivery [AOR 7.17 (2.48-20.73)], experiencing labor complications [AOR=8.99 (3.11-25.98)], maternal HIV infection [AOR=5.36 (2.02-14.26)], antenatal care booking [AOR=0.32 (0.18-0.87)] and birth weight below 2500g [AOR=9.46 (3.91-27.65)]. Conclusion: Labor complications, belonging to Page number not for citation purposes 2 apostolic sect, having a home delivery, maternal HIV infection, low birth weight and antenatal care booking were independently associated with perinatal mortality. Health worker training in emergency management of obstetric and neonatal care was initiated. Marondera District started holding perinatal mortality meetings.

Economic Inequalities in Maternal Health Care: Prenatal Care and Skilled Birth Attendance in India, 1992–2006. PK Pathak, A Singh, et al. PLoS ONE, 5(10): e13593.

Background: The use of maternal health care is limited in India despite several programmatic efforts for its improvement since the late 1980's. The use of maternal health care is typically patterned on socioeconomic and cultural contours. However, there is no clear perspective about how socioeconomic differences over time have contributed towards the use of maternal health care in India. Methodology/Principal Findings: Using data from three rounds of National Family Health Survey (NFHS) conducted during 1992–2006, we analyse the trends and patterns in utilization of prenatal care (PNC) in first trimester with four or more antenatal care visits and skilled birth attendance (SBA) among poor and nonpoor mothers, disaggregated by area of residence in India and three contrasting provinces, namely, Uttar Pradesh, Maharashtra and Tamil Nadu. In addition, we investigate the relative contribution of public and private health facilities in meeting the demand for SBA, especially among poor mothers. We also examine the role of salient socioeconomic, demographic and cultural factors in influencing aforementioned outcomes. Bivariate analyses, concentration curve and concentration index, logistic regression and multinomial logistic regression models are used to understand the trends, patterns and predictors of the two outcome variables. Results indicate sluggish progress in utilization of PNC and SBA in India and selected provinces during 1992–2006. Enormous inequalities in utilization of PNC and SBA were observed largely to the disadvantage of the poor. Multivariate analysis suggests growing inequalities in utilization of the two outcomes across different economic groups. Conclusions: The use of PNC and SBA remains disproportionately lower among poor mothers in India irrespective of area of residence and province. Despite several governmental efforts to increase access and coverage of delivery services to poor, it is clear that the poor (a) do not use SBA and (b) even if they had SBA, they were more likely to use the private providers.

Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study. CJ Gill, G Phiri-Mazala, NG Guerina, et al. BMJ; 2011; 342:d346, February 2011

Objective To determine whether training traditional birth attendants to manage several common perinatal conditions could reduce neonatal mortality in the setting of a resource poor country with limited access to healthcare. Design Prospective, cluster randomised and controlled effectiveness study. Setting Lufwanyama, an agrarian, poorly developed district located in the Copperbelt province, Zambia. All births carried out by study birth attendants occurred at mothers’ homes, in rural village settings. Participants 127 traditional birth attendants and mothers and their newborns (3559 infants delivered regardless of vital status) from Lufwanyama district. Interventions Using an unblinded design, birth attendants were cluster randomised to intervention or control groups. The intervention had two components: training in a modified version of the neonatal resuscitation protocol, and single dose amoxicillin coupled with facilitated referral of infants to a health centre. Control birth attendants continued their existing standard of care (basic obstetric skills and use of clean delivery kits). Main outcome measures The primary outcome was the proportion of liveborn infants who died by day 28 after birth, with rate ratios statistically adjusted for clustering. Secondary outcomes were mortality at different time points; and comparison of causes of death based on verbal autopsy data. Results Among 3497 deliveries with reliable information, mortality at day 28 after birth was 45% lower among liveborn infants delivered by intervention birth attendants than control birth attendants (rate ratio 0.55, 95% confidence interval 0.33 to 0.90). The greatest reductions in mortality were in the first 24 hours after birth: 7.8 deaths per 1000 live births for infants delivered by intervention birth attendants compared with 19.9 per 1000 for infants delivered by control birth attendants (0.40, 0.19 to 0.83). Deaths due to birth asphyxia were reduced by 63% among infants delivered by intervention birth attendants (0.37, 0.17 to 0.81) and by 81% within the first two days after birth (0.19, 0.07 to 0.52). Stillbirths and deaths from serious infection occurred at similar rates in both groups. Conclusions Training traditional birth attendants to manage common perinatal conditions significantly reduced neonatal mortality in a rural African setting. This approach has high potential to be applied to similar settings with dispersed rural populations. 

Impact of a Training Package for Community Birth Attendants in Madagascar. O Lucey, M Andriatsihosena, M Ellis. Journal of Tropical Pediatrics, 57 (1): 59-61, 2011.

This brief report assesses the impact of community birth attendant training and explores barriers to safe delivery in rural Madagascar. We assessed the knowledge of 25 community birth attendants using interviewer-administered questionnaires and explored attitudes to delivery in 4 focus groups of 10 women of reproductive age and 1 focus group of 10 birth attendants. We found a mismatch between hygiene knowledge and reported practice. Clinical experience appears to reinforce training to achieve longer lasting change in practitioner knowledge (e.g. of labour complications). Focus groups helped to identify practical barriers to clean (delivery kits) and safe delivery (cost) despite this knowledge. We proposed that a facilitated women’s group programme may complement such training.

Impact of Pregnancy-Induced Hypertension on Stillbirth and Neonatal Mortality in First and Higher Order Births: A Population-Based Study*. CV Ananth, O Basso. Epidemiology., 21(1): 118–123, January 2011.

Background: Hypertensive disorders of pregnancy are more frequent in primiparous women, but may be more severe in multiparas. We examined trends in pregnancy-induced hypertension (PIH)-related stillbirth and neonatal mortality and explored whether mortality varied by parity and maternal race. Methods: We carried out a population-based study of 57 million singleton live- and stillbirths (24-46 weeks) in the United States between 1990 and 2004. We estimated rates and adjusted odds ratio (OR) of stillbirth and neonatal death in relation to PIH, comparing births in 1990-91 with 2003-04. Results: PIH increased from 3.0% in 1990 to 3.9% in 2004. In both 1990-91 and 2003-04 periods, PIH was associated with an increased risk of stillbirth and neonatal death. We explored this in more detail in 2003-04, and observed that the increased risk of stillbirth was higher in women having their second or higher order births (OR=2.24, 95% confidence interval (CI)=2.11-2.37) compared with women having their first birth (OR=1.52, 95% CI=1.40-1.64). Patterns were similar for neonatal death (OR=1.30, 95% CI=1.18-1.43 in first and OR=1.64, 95% CI=1.51-1.78 in second or higher order births). Among multiparas, the association between PIH and stillbirth was stronger in Blacks (OR=2.93, 95% CI=2.66-3.22) than Whites (OR=1.98, 95% CI=1.83-2.14). Conclusions: A substantial burden of stillbirth and neonatal mortality is associated with PIH, especially among multiparas women, which may be due to more severe disease women, or to a higher burden of underlying disease.

Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial*. ZA Bhutta, S Soofi, S Cousens, et al. The Lancet, 377, 9763, January 2011.

Background: Newborn deaths account for 57% of deaths in children younger than 5 years in Pakistan. Although a large programme of trained lady health workers (LHWs) exists, the effectiveness of this training on newborn outcomes has not been studied. We aimed to evaluate the effectiveness of a community-based intervention package, principally delivered through LHWs working with traditional birth attendants and community health committees, for reduction of perinatal and neonatal mortality in a rural district of Pakistan. Methods: We undertook a cluster randomised trial between February, 2006, and March, 2008, in Hala and Matiari subdistricts, Pakistan. Catchment areas of primary care facilities and all affiliated LHWs were used to define clusters, which were allocated to intervention and control groups by restricted, stratified randomisation. The intervention package delivered by LHWs through group sessions consisted of promotion of antenatal care and maternal health education, use of clean delivery kits, facility births, immediate newborn care, identification of danger signs, and promotion of careseeking; control clusters received routine care. Independent data collectors undertook quarterly household surveillance to capture data for births, deaths, and household practices related to maternal and newborn care. Data collectors were masked to cluster allocation; those analysing data were not. The primary outcome was perinatal and all-cause neonatal mortality. Analysis was by intention to treat. This trial is registered, ISRCTN16247511. Findings: 16 clusters were assigned to intervention (23 353 households, 12 391 total births) and control groups (23 768 households, 11 443 total births). LHWs in the intervention clusters were able to undertake 4428 (63%) of 7084 planned group sessions, but were only able to visit 2943 neonates (24%) of a total 12 028 livebirths in their catchment villages. Stillbirths were reduced in intervention clusters (39·1 stillbirths per 1000 total births) compared with control (48·7 per 1000; risk ratio [RR] 0·79, 95% CI 0·68—0·92; p=0·006). The neonatal mortality rate was 43·0 deaths per 1000 livebirths in intervention clusters compared with 49·1 per 1000 in control groups (RR 0·85, 0·76—0·96; p=0·02). Interpretation: Our results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers and emphasise the need for attention to issues of programme management and coverage for such initiatives to achieve maximum potential.

Malaria Prevention with IPTp during Pregnancy Reduces Neonatal Mortality. C Menéndez , A Bardají, B Sigauque, et al. PLoS ONE, January 2011.

Background: In the global context of a reduction of under-five mortality, neonatal mortality is an increasingly relevant component of this mortality. Malaria in pregnancy may affect neonatal survival, though no strong evidence exists to support this association. Methods: In the context of a randomised, placebo-controlled trial of intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine (SP) in 1030 Mozambican pregnant women, 997 newborns were followed up until 12 months of age. There were 500 live borns to women who received placebo and 497 to those who received SP. Findings: There were 58 infant deaths; 60.4% occurred in children born to women who received placebo and 39.6% to women who received IPTp (p = 0.136). There were 25 neonatal deaths; 72% occurred in the placebo group and 28% in the IPTp group (p = 0.041). Of the 20 deaths that occurred in the first week of life, 75% were babies born to women in the placebo group and 25% to those in the IPTp group (p = 0.039). IPTp reduced neonatal mortality by 61.3% (95% CI 7.4%, 83.8%); p = 0.024]. Conclusions: Malaria prevention with SP in pregnancy can reduce neonatal mortality. Mechanisms associated with increased malaria infection at the end of pregnancy may explain the excess mortality in the malaria less protected group. Alternatively, SP may have reduced the risk of neonatal infections. These findings are of relevance to promote the implementation of IPTp with SP, and provide insights into the understanding of the pathophysiological mechanisms through which maternal malaria affects fetal and neonatal health. 

Maternal, neonatal, and child health in southeast Asia: towards greater regional collaboration*. CS Acuin, GL Khor, T Liabsuetrakul, et al. The Lancet, Early Online Publication, January 2011.

Although maternal and child mortality are on the decline in southeast Asia, there are still major disparities, and greater equity is key to achieve the Millennium Development Goals. We used comparable cross-national data sources to document mortality trends from 1990 to 2008 and to assess major causes of maternal and child deaths. We present inequalities in intervention coverage by two common measures of wealth quintiles and rural or urban status. Case studies of reduction in mortality in Thailand and Indonesia indicate the varying extents of success and point to some factors that accelerate progress. We developed a Lives Saved Tool analysis for the region and for country subgroups to estimate deaths averted by cause and intervention. We identified three major patterns of maternal and child mortality reduction: early, rapid downward trends (Brunei, Singapore, Malaysia, and Thailand); initially high declines (sustained by Vietnam but faltering in the Philippines and Indonesia); and high initial rates with a downward trend (Laos, Cambodia, and Myanmar). Economic development seems to provide an important context that should be coupled with broader health-system interventions. Increasing coverage and consideration of the health-system context is needed, and regional support from the Association of Southeast Asian Nations can provide increased policy support to achieve maternal, neonatal, and child health goals. 

Risk factors, morbidity and mortality of neonatal tetanus*. AC Dey, L Saha, M Shahidullah. Mymensingh Medical Journal, 20(1):54-8, January 2011.

A retrospective study was conducted to identify the risk factors, mortality and morbidity of neonatal tetanus in an Infectious Disease Hospital, Mohakhali, Dhaka, Bangladesh, the only referral hospital in the country of its kind. Hospital records of all cases of neonatal tetanus admitted over one year period from 1st May 2008 and 30th April 2009 were analyzed. Demographic data, clinical presentation, progression, hospital stay and outcome were evaluated. Overall mortality was found 52.9%. Hospital stay among the patients was 11.00±8.37 days. Among the patients about two third had unsatisfactory outcome and only 6(35.3%) patients recovered completely. The retrospective study identified that mortality due to neonatal tetanus was very high and the common morbidities were lock jaw, inability to suck, abdominal rigidity, convulsion, fever, irritability etc. It has been explored that low socioeconomic conditions, mothers' illiteracy, lack of antenatal care and involvement of untrained persons during delivery of baby and unclean cord care practices were the important factors contributing to neonatal tetanus. A further study with a larger sample size is recommended for evaluating the findings of the study and formulating the possible preventive strategies against neonatal tetanus.

Setting Research Priorities to Reduce Almost One Million Deaths from Birth Asphyxia by 2015. JE Lawn, R Bahl, S Bergstrom, ZA Bhutta, GL Darmstadt, et al. PLoS Med, January 2011.

•   Intrapartum-related neonatal deaths (previously called “birth asphyxia”) are the fifth most common cause of deaths among children under 5 years of age, accounting for an estimated 814,000 deaths each year, and also associated with significant morbidity, resulting in a burden of 42 million disability adjusted life years (DALYs).

•   This paper uses a systematic process developed by the Child Health Nutrition Research Initiative (CHNRI) to define and rank research options to reduce mortality from intrapartum-related neonatal deaths by the year 2015, in order to advance Millennium Development Goal (MDG) 4 for child survival.

•   A list of 61 research questions was developed and scored by 21 technical experts. The top one-third of the ranked research investment options was dominated by delivery (implementation) research, whilst discovery (basic science) questions were not ranked highly, especially for expected reduction of mortality and inequity in the short time to 2015.

•   Among the top four research questions, two relate to generation of demand for facility care at birth with specific mechanisms (such as transport and communication schemes, or financial incentives and conditional cash transfers). The other two top ranked priorities relate to use of community cadres and the roles they might effectively play—for example, screening for complications or supportive transfer to facilities and companionship at birth. The highest ranked discovery question concerned the interaction of hypoxia and infection, and the highest ranked epidemiologic question addressed prediction of intrapartum hypoxic injury.

•   This exercise highlights the need for current research investments to focus on studies most likely to result in accelerated progress towards MDG 4 and in the countries where the most deaths occur.

*Journal registration required for full access