Research Round-Up: June 2011

Are birth kits a good idea? A systematic review of the evidence.* VA Hundley, BI. Avan,D Braunholtz, WJ. Graham. Midwifery In Press, Corrected Proof.

Objective: to identify the current state of knowledge regarding the effects of births kits on clean birth practices and on newborn and maternal outcomes. Design: the scoping review was informed through a systematic literature review; a call for information distributed to experts in maternal and child health, relevant research centres and specialist libraries; and a search of the web sites of groups working in the area of maternal and child health. Data were synthesised to produce a summary of the state of knowledge regarding birth kits. Meta-analysis was not attempted because of the varied study designs and the heterogeneous nature of the interventions. Participants: births kit use was identified in 51 low resource countries, but evaluations were scarce, with only nine studies reporting effects of intervention packages including births kits. Findings: the quality of evidence for inferring causality was weak, with only one randomised controlled trial. In two studies, births kit use along with co-interventions resulted in a statistically significant increase in the likelihood of the attendant having clean hands. The impact on other aspects of cleanliness was less clear. Intervention packages which include births kits were associated with reduced newborn mortality (three studies), omphalitis (four studies), and puerperal sepsis (three studies). The one study that considered maternal mortality was not large enough to estimate relative reduction with much precision. None of the studies reported any adverse effects; however, none explicitly described looking for negative consequences. Conclusion: providing birth kits to facilitate clean practices seems commonsense, but there is no evidence to indicate effects, positive or negative, separate from those achieved by a broader intervention package. More robust methods and knowledge systems are needed to understand the contextual factors and share relevant implementation lessons. 

Causes of stillbirth, neonatal death and early childhood death in rural Zambia by verbal autopsy assessments.* E Turnbull, MK Lembalemba, M Brad Guffey, C Bolton-Moore, M Mubiana-Mbewe, N Chintu, MJ Giganti, M Nalubamba-Phiri, EM Stringer, JSA Stringer, BH Chi. Tropical Medicine & International Health, 16: 894–901, July 2011. 

Objectives: To describe specific causes of the high rates of stillbirth, neonatal death and early child childhood death in Zambia. Methods: We conducted a household-based survey in rural Zambia. Socio-demographic and delivery characteristics were recorded, alongside a maternal HIV test. Verbal autopsy questionnaires were administered to elicit mortality-related information and independently reviewed by three experienced paediatricians who assigned a cause and contributing factor to death. For this secondary analysis, deaths were categorized into: stillbirths (foetal death ≥28 weeks of gestation), neonatal deaths (≤28 days) and early childhood deaths (>28 days to <2 years). Results: Among 1679 households, information was collected on 148 deaths: 34% stillbirths, 26% neonatal and 40% early childhood deaths. Leading identifiable causes of stillbirth were intrauterine infection (26%) and birth asphyxia (18%). Of 32 neonatal deaths, 38 (84%) occurred within the first week of life, primarily because of infections (37%) and prematurity (34%). The majority of early childhood deaths were caused by suspected bacterial infections (82%). HIV prevalence was significantly higher in mothers who reported an early childhood death (44%) than mothers who did not (17%; P < 0.01). Factors significantly associated with mortality were lower socio-economic status (P < 0.01), inadequate water or sanitation facilities (P < 0.01), home delivery (P = 0.04) and absence of a trained delivery attendant (P < 0.01). Conclusion: We provide community-level data about the causes of death among children under 2 years of age. Infectious etiologies for mortality ranked highest. At a public health level, such information may have an important role in guiding prevention and treatment strategies to address perinatal and early childhood mortality.

Community Health Workers Can Identify and Manage Possible Infections in Neonates and Young Infants: MINI-A Model from Nepal. S Khanal, J Sharma, V Singh GC, P Dawson, R Houston, N Khadka, B Yengden. Journal of Health, Population and Nutrition. Vol. 29 No. 3 Jun 2011.

The mortality rates of infants and children aged less than five years are declining globally and in Nepal but less among neonates. Most deliveries occur at home without skilled attendants, and most neonates may not receive appropriate care through the existing medical systems. So, a community-based pilot programme—Morang Innovative Neonatal Intervention (MINI) programme—was implemented in Morang district of Nepal to see the feasibility of bringing the management of sick neonates closer to home. The objective of this model was to answer the question: “Can a team of female community health volunteers and paid facility-based community health workers (collectively called CHWs) within the existing heath system correctly follow a set of guidelines to identify possible severe bacterial infection in neonates and young infants and successfully deliver their treatment?” In the MINI model, the CHWs followed an algorithm to classify sick young infants with possible severe bacterial infection (PSBI). Female Community Health Volunteers (FCHVS) were trained to visit homes soon after delivery, record the birth, counsel mothers on essential newborn care, and assess the newborns for danger-signs. Infants classified as having PSBI, during this or subsequent contacts, were treated with co-trimoxazole and referred to facility-based CHWs for seven-day treatment with injection gentamicin. Additional supervisory support was provided for quality of care and intensified monitoring. Of 11,457 livebirths recorded during May 2005–April 2007, 1,526 (13.3%) episodes of PSBI were identified in young infants. Assessment of signs by the FCHVs matched that of more highly-trained facility-based CHWs in over 90% of episodes. Treatment was initiated in 90% of the PSBI episodes; 93% completed a full course of gentamicin. Case fatality in those who received treatment with gentamicin was 1.5% [95% confidence interval (CI) 1.0-2.3] compared to 5.3% (95% CI 2.6-9.7) in episodes that did not receive any treatment. Within the existing government health infrastructure, the CHWs can assess and identify possible infections in neonates and young infants and deliver appropriate treatment with antibiotics. This will result in improvement in the likelihood of survival and address one of the main causes of neonatal mortality.

Community interventions to reduce child mortality in Dhanusha, Nepal: study protocol for a cluster randomized controlled trial. BP. Shrestha, B Bhandari, DS. Manandhar, D Osrin, A Costello, N Saville. Trials 2011, 12:136, June 2011.

Neonatal mortality remains high in rural Nepal. Previous work suggests that local women's groups can effect significant improvement through community mobilisation. The possibility of identification and management of newborn infections by community-based workers has also arisen. Methods / DesignThe objective of this trial is to evaluate the effects on newborn health of two community-based interventions involving Female Community Health Volunteers. MIRA Dhanusha community groups: a participatory intervention with women's groups. MIRA Dhanusha sepsis management: training of community volunteers in the recognition and management of neonatal sepsis. The study design is a cluster randomized controlled trial involving 60 village development committee clusters allocated 1:1 to two interventions in a factorial design. MIRA Dhanusha community groups: Female Community Health Volunteers (FCHVs) are supported in convening monthly women's groups. Nine groups per cluster (270 in total) work through two action research cycles in which they (i) identify local issues around maternity, newborn health and nutrition, (ii) prioritise key problems, (iii) develop strategies to address them, (iv) implement the strategies, and (v) evaluate their success. Cycle 1 focuses on maternal and newborn health and cycle 2 on nutrition in pregnancy, and infancy and associated postpartum care practices. MIRA Dhanusha sepsis management: FCHVs are trained to care for vulnerable newborn infants. They (i) identify local births, (ii) identify low birth weight infants, (iii) identify possible newborn infection, (iv) manage the process of treatment with oral antibiotics and referral to a health facility to receive parenteral gentamicin, and (v) follow up infants and support families. Primary outcome: neonatal mortality rates. Secondary outcome: MIRA Dhanusha community groups: stillbirth, infant and under-two mortality rates, care practices and health care seeking behaviour, maternal diet, breastfeeding and complementary feeding practices, maternal and under-2 anthropometric status. MIRA Dhanusha sepsis management: identification and treatment of neonatal sepsis by community health volunteers, infection-specific neonatal mortality.

Community mobilisation and health management committee strengthening to increase birth attendance by trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomised controlled trial.  JMorrison, KTumbahangphe, BBudhathoki, RNeupane, ASen, KDahal, RThapa, RManandhar, DManandhar, ACostello, DOsrin. Trials 2011, 12:128.

Background: Birth attendance by trained health workers is low in rural Nepal. Local participation in improving health services and increased interaction between health systems and communities may stimulate demand for health services. Significant increases in birth attendance by trained health workers may be affected through community mobilisation by local women's groups and health management committee strengthening. We will test the effect of community mobilisation through women's groups, and health management committee strengthening, on institutional deliveries and home deliveries attended by trained health workers in Makwanpur District. Design: Cluster randomised controlled trial involving 43 village development committee clusters. 21 clusters will receive the intervention and 22 clusters will serve as control areas. In intervention areas, Female Community Health Volunteers are supported in convening monthly women's groups. The groups work through an action research cycle in which they consider barriers to institutional delivery. Groups then plan and implement strategies to address these barriers with their communities, and evaluate their progress. Health management committees participate in three-day workshops that use appreciative inquiry methods to explore and plan ways to improve maternal and newborn health services. Follow-up meetings are conducted every three months to review progress. Primary outcomes are institutional deliveries and home deliveries conducted by trained health workers. Secondary outcome measures include uptake of antenatal and postnatal care, neonatal mortality and stillbirth rates, and maternal morbidity.

Human resources for maternal, newborn and child health: from measurement and planning to performance for improved health outcomes. NGupta, BMaliqi, AFranca, FNyonator, MA Pate, DSanders, HBelhadj, BDaelmans. Human Resources for Health 2011, 9:16.

Background: There is increasing attention, globally and in countries, to monitoring and addressing the health systems and human resources inputs, processes and outputs that impede or facilitate progress towards achieving the Millennium Development Goals for maternal and child health. We reviewed the situation of human resources for health (HRH) in 68 low- and middle-income countries that together account for over 95% of all maternal and child deaths. Methods: We collected and analysed cross-nationally comparable data on HRH availability, distribution, roles and functions from new and existing sources, and information from country reviews of HRH interventions that are associated with positive impacts on health services delivery and population health outcomes. Results: Findings from 68 countries demonstrate availability of doctors, nurses and midwives is positively correlated with coverage of skilled birth attendance. Most (78%) of the target countries face acute shortages of highly skilled health personnel, and large variations persist within and across countries in workforce distribution, skills mix and skills utilization. Too few countries appropriately plan for, authorize and support nurses, midwives and community health workers to deliver essential maternal, newborn and child health-care interventions that could save lives. Conclusions: Despite certain limitations of the data and findings, we identify some key areas where governments, international partners and other stakeholders can target efforts to ensure a sufficient, equitably distributed and efficiently utilized health workforce to achieve MDGs 4 and 5.

Methodology and tools for quality improvement in maternal and newborn health care.* Raven, J., J. Hofman, et al. (2011). International Journal of Gynecology & Obstetrics 114(1): 4-9.

Objective: To gain an overview of approaches, methodologies, and tools used in quality improvement of maternal and newborn health in low-income countries. Methods: Electronic search of MEDLINE and organizational databases for literature describing approaches, methodologies, and tools used to improve the quality of maternal and newborn health care in low-income countries. Relevant papers and reports were reviewed and summarized. Results: Developing a culture of quality is an important requisite for successful quality improvement. Methodologies to improve quality include the development of standards and guidelines and the performance of mortality, near-miss, and criterion-based audits. Tools for data collection and process description were identified, and examples of work to improve quality of care are provided. Conclusion: The documented experience with the identified approaches, methodologies, and tools indicates that none is sufficient by itself to achieve a desirable improvement in quality of care. The choice of methodologies and tools depends on the healthcare system and its available resources. There is a lack of studies that describe the process of quality improvement and a need for research to provide evidence of the effectiveness of the identified methods and tools.

Monitoring and evaluation of skilled birth attendance: A proposed new framework.* Adegoke, Adetoro A., Hofman, Jan J., Kongnyuy, Eugene J., & van den Broek, Nynke. (2011). Midwifery, 27(3), 350-359.

Background: the Maternal Mortality Ratio (MMR) and proportion of births attended by skilled attendants are the two indicators selected to measure progress towards the achievement of MDG five. By the year 2015, the international community aims to have achieved a 75% reduction in MMR and 90% coverage of women having a skilled attendant at birth. In spite of the importance of this indicator, there is little consistency in how this is monitored and evaluated. This paper provides a review of the literature on the approaches and conceptual frameworks for evaluating progress with skilled birth attendance (SBA). The applicability of current frameworks is reviewed and a new simplified framework for monitoring and evaluation of SBA is proposed. Methods: We searched electronic databases, internet, publications and databases of organisations. We hand searched reference lists of key papers, using search terms such as skilled attend*, maternal health, maternal mortality, midwi*, health professional, impact*, monitor* and evaluat*. Findings: there were 44 potentially relevant articles from PUBMED, three from Scopus, seven from WHO, two from UNFPA, one obtained via hand search and one via personal communication. A total of 27 publications were found to be relevant after a review of their abstracts. Of these, 17 were on SBA and maternal mortality, and 10 were on monitoring and evaluation of SBA. Of the publications on monitoring and evaluation of SBA, two studies assessed global coverage of SBA, eight studies evaluated specific programmes and three of these had a `conceptual framework'. Conclusions: no standard framework to evaluate progress made in ensuring increased coverage with skilled birth attendance currently exists. There are three published conceptual frameworks, each of which has valuable and workable components as well as limitations. A simplified systems approach to the Monitoring and Evaluation of SBA using structure, process and outcome criteria is proposed.

Neonatal outcomes among multiple births less than or equal to 32 weeks gestational age: Does mode of conception have an impact? A Cohort Study. V Shah, H AlWassia, K Shah, W Yoon, P Shah. BMC Pediatrics, 14 June 2011.

Background: Studies comparing perinatal outcomes in multiples conceived following the use of artificial reproductive technologies (ART) vs. spontaneous conception (SC) have reported conflicting results in terms of mortality and morbidity. Therefore, the objective of our study was to compare composite outcome of mortality and severe neonatal morbidities amongst preterm multiple births < 32 weeks gestation infant born following ART vs. SC. Methods: We conducted a single center cohort study at Mount Sinai Hospital, Toronto, Ontario, Canada. Data on all preterm multiple births (< 32 weeks GA) discharged between July 2005 and June 2008 were retrospectively collected from a prospective database at our centre. Details regarding mode of conception were collected retrospectively from maternal health records. Preterm multiple births were categorized into those born following ART vs. SC. Composite outcome was defined as combination of death or any of the three neonatal morbidities (grade 3/4 intraventricular hemorrhage or periventricular leukomalacia; retinopathy of prematurity > stage 2 or chronic lung disease). Univariate and multivariate regression analysis were preformed after adjustment of confounders (maternal age, parity, triplets, gestational age, sex, and small for gestational age). Results: One hundred and thirty seven neonates were born following use of ART and 233 following SC. The unadjusted composite outcome rate was significantly higher in preterm multiples born following ART vs. SC [43.1% vs. 26.6%, p=0.001; OR 1.98 (95% CI 1.13, 3.45)]; however, when adjusted for confounders the difference between groups was not statistically significant [OR 1.39, 95% CI 0.67, 2.89]. Conclusion: In our population of preterm multiple births, the mode of conception had no detectable effect on the adjusted composite neonatal outcome of mortality and/or three neonatal morbidities.

Newborn care and knowledge translation - perceptions among primary healthcare staff in northern Vietnam. L Eriksson, N Thu Nga, DP Hoa, LA Persson, U Ewald, L Wallin. Implementation Science, 6: 29.

Background: Nearly four million neonatal deaths occur annually in the world despite existing evidence-based knowledge with the potential to prevent many of these deaths. Effective knowledge translation (KT) could help to bridge this know-do gap in global health. The aim of this study was to explore aspects of KT at the primary healthcare level in a northern province in Vietnam. Methods: Six focus-group discussions were conducted with primary healthcare staff members who provided neonatal care in districts that represented three types of geographical areas existing in the province (urban, rural, and mountainous). Recordings were transcribed verbatim, translated into English, and analyzed using content analysis. Results: We identified three main categories of importance for KT. Healthcare staff used several channels for acquisition and management of knowledge (1), but none appeared to work well. Participants preferred formal training to reading guideline documents, and they expressed interest in interacting with colleagues at higher levels, which rarely happened. In some geographical areas, traditional medicine (2) seemed to compete with evidence-based practices, whereas in other areas it was a complement. Lack of resources, low frequency of deliveries and, poorly paid staff were observed barriers to keeping skills at an adequate level in the healthcare context (3). Conclusions: This study indicates that primary healthcare staff work in a context that to some extent enables them to translate knowledge into practice. However, the established and structured healthcare system in Vietnam does constitute a base where such processes could be expected to work more effectively. To accelerate the development, thorough considerations over the current situation and carefully targeted actions are required.

Obstetric quality assurance to reduce maternal and fetal mortality in Kano and Kaduna State hospitals in Nigeria.* Galadanci, H., W. Künzel, et al. (2011). International Journal of Gynecology & Obstetrics 114(1): 23-28.

Objective: To achieve Millennium Development Goals 4 and 5 in Nigeria, a quality assurance project in obstetrics in 10 hospitals in northern Nigeria was established to improve maternal and fetal outcome. Methods: The project commenced in January 2008 with assessment and improvement of the structure of the 10 hospitals. Continuous maternal and fetal data collection and analysis were conducted from 2008 to 2009 by means of a maternity record book and structured monthly summary form. The quality of hospital infrastructure and equipment was also assessed. Results: The mean maternal mortality ratio (MMR) was reduced from 1790 per 100 000 births in the first half of 2008 to 940 per 100 000 births in the second half of 2009. The average fetal mortality ratio (FMR) decreased slightly from 84.9 to 83.5 per 1000 births. There was an inversely proportional relationship between the total number of deliveries in a hospital and MMR and FMR. There was a close correlation between the MMR and the equipment status and hygiene conditions of the hospitals. Conclusion: Continuous monitoring of quality assurance in maternity units raised the awareness of the quality of obstetric performance and improved the quality of care provided, thereby improving MMR.

Rural-urban differences in neonatal mortality in a poorly developed province of China. B Yi, L Wu, H Liu, W Fang, Y Hu, Y Wang. BMC Public Health 2011, 11:477, June 18 2011.

Background: The influence of rural-urban disparities in children's health on neonatal death in disadvantaged areas of China is poorly understood. In this study of rural and urban populations in Gansu province, a disadvantaged province of China, we describe the characteristics and mortality of newborn infants and evaluated rural-urban differences of neonatal death. Methods: We analyzed all neonatal deaths in the data from the Surveillance System of Child Death in Gansu Province, China from 2004 to 2009. We calculated all-cause neonatal mortality rates (NMR) and cause-specific death rates for infants born to rural or urban mothers during 2004-09. Rural-urban classifications were determined based on the residence registry system of China. Chi-square tests were used to compare differences of infant characteristics and cause-specific deaths by rural-urban maternal residence. Results: Overall, NMR fell in both rural and urban populations during 2004-09. Average NMR for rural and urban populations was 17.8 and 7.5 per 1000 live births, respectively. For both rural and urban newborn infants, the four leading causes of death were birth asphyxia, preterm or low birth weight, congenital malformation, and pneumonia. Each cause-specific death rate was higher in rural infants than in urban infants. More rural than urban neonates died out of hospital or did not receive medical care before death. Conclusions: Neonatal mortality declined dramatically both in urban and rural groups in Gansu province during 2004-09. However, profound disparities persisted between rural and urban populations. Strategies that address inequalities of accessibility and quality of health care are necessary to improve neonatal health in rural settings in China.

Special Delivery: An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World.* T Tamrat and S Kachnowski. Maternal and Child Health Journal.

Mobile health (mHealth) encompasses the use of mobile telecommunication and multimedia into increasingly mobile and wireless health care delivery systems and has the potential to improve tens of thousands of lives each year. The ubiquity and penetration of mobile phones presents the opportunity to leverage mHealth for maternal and newborn care, particularly in under-resourced health ecosystems. Moreover, the slow progress and funding constraints in attaining the Millennium Development Goals for child and maternal health encourage harnessing innovative measures, such as mHealth, to address these public health priorities. This literature review provides a schematic overview of the outcomes, barriers, and strategies of integrating mHealth to improve prenatal and neonatal health outcomes. Six electronic databases were methodically searched using predetermined search terms. Retrieved articles were then categorized according to themes identified in previous studies. A total of 34 articles and reports contributed to the findings with information about the use and limitations of mHealth for prenatal and neonatal healthcare access and delivery. Health systems have implemented mHealth programs to facilitate emergency medical responses, point-of-care support, health promotion and data collection. However, the policy infrastructure for funding, coordinating and guiding the sustainable adoption of prenatal and neonatal mHealth services remains under-developed. The integration of mobile health for prenatal and newborn health services has demonstrated positive outcomes, but the sustainability and scalability of operations requires further feedback from and evaluation of ongoing programs.

Tracking progress towards equitable child survival in a Nicaraguan community: neonatal mortality challenges to meet the MDG 4. W Perez, R Pena, LA Persson, C Kallestal. BMC Public Health 2011, 11:455, 9 June 2011.

Background: Nicaragua has made progress in the reduction of the under-five mortality since 1980s. Data for the national trends indicate that this poor Central American country is on track to reach the Millennium Development Goal-4 by 2015. Despite this progress, neonatal mortality has not showed same progress. The aim of this study is to analyse trends and social differentials in neonatal and under-five mortality in a Nicaraguan community from 1970 to 2005. Methods: Two linked community-based reproductive surveys in 1993 and 2002 followed by a health and demographic surveillance system providing information on all births and child deaths in urban and rural areas of Leon municipality, Nicaragua. A total of 49 972 live births were registered. Results: A rapid reduction in under-five mortality was observed during the late 1970s (from 103 deaths/1000 live births) and the 1980s, followed by a gradual decline to the level of 23 deaths/1000 live births in 2005. This community is on track for the Millennium Development Goal 4 for improved child survival. However, neonatal mortality increased lately in spite of a good coverage of skilled assistance at delivery. After some years in the 1990s with a very small gap in neonatal survival between children of mothers of different educational levels this divide is increasing. Conclusions: After the reduction of high under-five mortality that coincided with improved equity in survival in this Nicaraguan community, the current challenge is the neonatal mortality where questions of an equitable perinatal care of good quality must be addressed.

Understanding socioeconomic inequalities in outcome of pregnancy and neonatal mortality associated with congenital anomalies.* L K Smith, J L S Budd, D J Field, E S Draper. Arch Dis Child Fetal Neonatal Ed 2011.

Aims To investigate socioeconomic inequalities in outcome of pregnancy and neonatal mortality associated with congenital anomalies. Methods Population-based registry study of 581 597 total births to mothers resident in the East Midlands and South Yorkshire regions of England 1998–2007. Outcome measures were socioeconomic variation in risk of congenital anomalies; pregnancy outcome; live birth incidence and neonatal mortality. Nine anomalies audited as part of the UK Fetal Anomaly Screening Programme were included. Deprivation measured using the Index of Multiple Deprivation 2004. Results There were 1579 fetuses with one or more selected anomalies. There was no evidence of variation in the risk of anomalies with deprivation (rate ratio comparing the most deprived with the least deprived decile: 1.05 (0.89, 1.23)). 86% of anomalies were detected antenatally and there was no evidence that this varied with deprivation (rate ratio 0.99 (0.84, 1.17)). However fetuses from the most deprived decile diagnosed with an anomaly in the antenatal period were significantly less likely to be terminated than those from the least deprived areas (rate ratio 0.79 (0.65, 0.97)). Consequently there was a wide deprivation gap in the rate of live births with an anomaly (rate Ratio:1.61 (1.21, 2.15)) and neonatal mortality (rate ratio:1.97 (1.20, 3.27)). Conclusions Screening for congenital anomaly has reduced neonatal mortality through termination of pregnancy. However, socioeconomic variation in termination of pregnancy for fetal anomaly has resulted in a wide deprivation gap in live born infants with a congenital anomaly and subsequent neonatal mortality.

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