Research Round-Up: October 2011

Care seeking for fatal illness episodes in Neonates: a population-based study in rural Bangladesh.HR Chowdhury, SC Thompson, M Ali, et al. BMC Pediatrics, 11:88doi:10.1186/1471-2431-11-88, Oct 2011

Background: Poor neonatal health is a major contributor to under-five mortality in developing countries. A major constraint to effective neonatal survival programme has been the lack of population level data in developing countries. This study investigated the consultation patterns of caregivers during neonatal fatal illness episodes in the rural Matlab sub-district of eastern Bangladesh. Methods:Neonatal deaths were identified through a population-based demographic surveillance system in Matlab ICDDR,B maternal and child health (MCH) project area and an adjoining government service area. Trained project staff administered a structured questionnaire on care seeking to mothers at home who had experienced a neonatal death. Univariate, bivariate and binary multivariate logistic regressions were performed to describe care seeking during the fatal illness episode. Results: Of the 365 deaths recorded during 2003 and 2004, 84% died in the early (0-7days) neonatal period, with the remaining deaths occurring over the subsequent 8 to 28 days. The first resort of care by parents was a qualified doctor or paramedic in 37% of cases, followed by traditional and unqualified health care providers in 25%, while 38% sought no care. Thus, almost two thirds (63%) of neonates who died received only traditional and unqualified care or no care at all during their final illness episode. About 22% sought care from more than one provider, including 6% from 3 or more providers. Such plurality in care seeking was more likely among male infants, in the late neonatal period, and in the MCH project area. Conclusions: The high proportion of neonatal deaths that had received traditional care or no medical care in a rural area of Bangladesh highlights the need to develop community awareness about prompt medical care seeking for neonatal illnesses and to improve access to effective health care. Integration of traditional care providers into mainstream health programs should also be considered.

China's facility-based birth strategy and neonatal mortality: a population-based epidemiological study.*  XL Feng, S Guo, D Hipgrave, et al. The Lancet, Sept 2011.

Background: China's success in improving the quality of and access to obstetric care in hospitals offers an opportunity to examine the effect of a large-scale facility-based strategy on neonatal mortality. We aimed to establish this effect by assessing how the institutional strategy of intrapartum care has affected neonatal mortality and its regional inequalities. Methods: We did a population-based epidemiological study of China's National Maternal and Child Mortality Surveillance System from 1996 to 2008. We used data from 116 surveillance sites in China (37 urban districts and 79 rural counties) to examine neonatal mortality by cause, socioeconomic region, and place of birth, with Poisson regression to calculate relative risks. Rural counties were categorised into types 1—4, with type 4 being the least developed. We report attributable risks and preventable fractions for hospital births versus home births. Findings: Neonatal mortality decreased by 62% between 1996 and 2008. The rate of neonatal mortality was much lower for hospital births than for home births in all regions, with relative risks (RR) ranging from 0·30 (95% CI 0·22—0·40) in type 2 rural counties, to 0·52 (0·33—0·83) in type 4 counties (p<0·0001). The proportion of neonatal deaths prevented by hospital birth ranged from 70% (95% CI 59·7—77·8) to 48% (16·9—67·3). Babies born in urban hospitals had a low rate of neonatal mortality (5·7 per 1000 livebirths); but those born in hospitals in type 4 rural counties were almost four times more likely to die than were children born in urban hospitals (RR 3·80, 2·53—5·72).Interpretation: Other countries can learn from China's substantial progress in reducing neonatal mortality. The major effect of China's facility-based strategy on neonatal mortality is much greater than that reported for community-based interventions. Our findings will provide a great impetus for countries to increase demand for and quality of facility-based intrapartum care.

Choosing the appropriate neonatal resuscitation device for village midwives.* I Ariawan, M Agustini, Y Seamans, et al. Journal of Perinatology 31, 664-670, Oct 2011, doi:10.1038/jp.2011.7

Objective: An appropriate neonatal resuscitation device for village midwives in Indonesia is chosen.Study Design: The study compared four neonatal resuscitation devices: Ambu neonate bag and mask, Topster bag and mask, Laerdal pediatric pocket mask and Tekno tube and mask. Functionality was tested by 40 village midwives who were also interviewed about ease of use. Ventilation volume was tested using a mannequin and computer interface. Other features were assessed by PATH engineers.Result: There was no significant difference in the ventilation volumes among the four devices or any difference in acceptability to midwives or infection prevention ability, but the tube and mask devices were considered easier to clean. Conclusion: Given the similarity in functionality, ease of use, infection prevention, and portability and the significant difference in price, public health experts and neonatologists chose the local tube and mask device for use by village midwives.

Indicators for availability, utilization, and quality of emergency obstetric care in Ethiopia, 2008.* K Admasu, A Haile-Mariam, P Bailey. International Journal of Gynecology & Obstetrics.  115(1): 101-105.

Objective: To report on the availability and quality of emergency obstetric and newborn care (EmONC) in Ethiopia. Methods: All licensed hospitals and health centers were visited and standard questionnaires were administered. In addition, a nonrandom systematic sample was taken of recent cesarean deliveries, partographs, and maternal deaths—and these cases were systematically reviewed. Health facilities were geocoded using geographic positioning system devices. Results: Too few facilities provided EmONC to meet the UN standards of 5 per 500 000 population, both nationally and in all but 2 regions. Only 7% of deliveries took place in institutions of any type, and only 3% in facilities that routinely provided all the signal functions. Only 6% of women with obstetric complications were treated in any health facility, half of whom were treated in fully functional EmONC facilities. Nationwide, 0.6% of expected deliveries were by cesarean. The mortality rate for women with serious obstetric complications (case fatality rate) was 2%. The cause of death was unknown in 10% of cases, and 21% were due to indirect causes (primarily malaria, anemia, and HIV-related). Conclusion: None of the indicators met UN standards. Ethiopia faces many challenges—not least geography—with regard to improving EmONC. Nevertheless, the government places high priority on improvement and has taken (and will continue to take) action to achieve Millennium Development Goals 4 and 5. This comprehensive survey serves both as a road map for planning strategies for improvement and as a baseline for measuring the impact of interventions.

Maternal and Foetal Outcomes among Pregnant Women Hospitalised due to Interpersonal Violence: A Population based study in Western Australia, 2002-2008. LB Meuleners, AH Lee, PA Janssen, et al. BMC Pregnancy and Childbirth, 11:70doi:10.1186/1471-2393-11-70

Background: Interpersonal violence is responsible for more ill-health and premature death in women under the age of 45 than other preventable health conditions, but findings concerning the effects of violence during pregnancy on both maternal and foetal health have been inconsistent. Methods: A retrospective population-based cohort study was undertaken using linked data from the Hospital Morbidity Data Collection and the Western Australian Midwives' Notification System from 2002 to 2008. The aim was to determine the association between exposure to interpersonal violence during pregnancy and adverse maternal and foetal health outcomes at the population level. Results: A total of 468 pregnant women were hospitalised for an incident of interpersonal violence during the study period, and 3,744 randomly selected pregnant women were included as the comparison group. The majority of violent events were perpetrated by the pregnant women's partner or spouse. Pregnant Indigenous women were over-represented accounting for 67% of all hospitalisations due to violence and their risk of experiencing adverse maternal outcomes was significantly increased compared to non-Indigenous women (adjusted odds ratio 1.53, 95% CI 1.21 to 1.95, p=0.01). Pregnant women hospitalised for an incident of interpersonal violence sustained almost double the risk for adverse maternal complications than the non-exposed group (95% CI 1.34 to 2.18, p<0.001). The overall risk for adverse foetal complications for pregnant women exposed to violence was increased two-fold (95% CI 1.50 to 2.76, p<0.001). Conclusions: The risk of adverse health outcomes for both the mother and the baby increases if a pregnant woman is hospitalised for an incident of interpersonal violence during pregnancy.

Neonatal Morbidity and Mortality in Tribal and Rural Communities in Central India. A Niswade, SP Zodpey, S Ughade, et al. Indian Journal of Community Medicine 36(2): 150–158.

Background and Objectives: Little is known about the natural history of neonates born in the rural and tribal areas in India. The Neonatal Disease Surveillance Study (NDSS) measures the incidence of high-priority neonatal diseases, neonatal health events and associated risk factors to plan appropriate and effective actions. Materials and Methods: The NDSS is being conducted in Ramtek Revenue Block, Nagpur district, Maharashtra state, given its considerably high level of neonatal mortality. All households from five selected primary health centers were screened. Both active and passive surveillance systems were used for systematic collection of mother's health during pregnancy and of baby's health from birth to 4 months after birth. First-year results from November 2006 to October 2007 are presented. Results: Pregnancy outcomes were available for 1,136 women, with an overall neonatal mortality of 73 per 1,000 live births. The pregnancy outcomes varied by gestational age of the baby; miscarriages and abortions were higher in tribal than in non-tribal women, and tribal women had higher rates of low-birth weight (LBW) neonates than non-tribal women. The main cause of neonatal mortality was LBW, followed by sepsis and respiratory illness. The mortality of non-tribal babies was most strongly associated with pre term. For tribal babies, mortality was also associated with maternal morbidity and delay in the initiation of breastfeeding. Interpretation and Conclusions:The NDSS provides valuable information on the potentially modifiable factors associated with increased likelihood of neonatal mortality and morbidity. The Neonatal Health Research Initiative is now developing community-based interventions to reduce the high rate of neonatal mortality and morbidity in the rural areas of India.

Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis.* R Lozano, H Wang, KJ Foreman, et al. The Lancet 378(9797): 1139-1165.

Summary Background: With 4 years until 2015, it is essential to monitor progress towards Millennium Development Goals (MDGs) 4 and 5. Although estimates of maternal and child mortality were published in 2010, an update of estimates is timely in view of additional data sources that have become available and new methods developed. Our aim was to update previous estimates of maternal and child mortality using better data and more robust methods to provide the best available evidence for tracking progress on MDGs 4 and 5. Methods: We update the analyses of the progress towards MDGs 4 and 5 from 2010 with additional surveys, censuses, vital registration, and verbal autopsy data. For children we estimate early neonatal (0–6 days), late neonatal (7–28 days), postneonatal (29–364 days), childhood (ages 1–4 years), and under-5 mortality. We use an improved model for estimating mortality by age under 5 years. For maternal mortality, our updated analysis includes greater than 1000 additional site-years of data. We tested a large set of alternative models for maternal mortality; we used an ensemble model based on the models with the best out-of-sample predictive validity to generate new estimates from 1990 to 2011. Findings: Under-5 deaths have continued to decline, reaching 7·2 million in 2011 of which 2·2 million were early neonatal, 0·7 million late neonatal, 2·1 million post neonatal, and 2·2 million during childhood (ages 1–4 years). Comparing rates of decline from 1990 to 2000 with 2000 to 2011 shows that 106 countries have accelerated declines in the child mortality rate in the past decade. Maternal mortality has also continued to decline from 409 100 (uncertainty interval 382 900–437 900) in 1990 to 273 500 (256 300–291 700) deaths in 2011. We estimate that 56 100 maternal deaths in 2011 were HIV-related deaths during pregnancy. Based on recent trends in developing countries, 31 countries will achieve MDG 4, 13 countries MDG 5, and nine countries will achieve both. Interpretation:  Even though progress on reducing maternal and child mortality in most countries is accelerating, most developing countries will take many years past 2015 to achieve the targets of the MDGs 4 and 5. Similarly, although there continues to be progress on maternal mortality the pace is slow, without any overall evidence of acceleration. Immediate concerted action is needed for a large number of countries to achieve MDG 4 and MDG 5.

Promoting male involvement to improve PMTCT uptake and reduce antenatal HIV infection: a cluster randomized controlled trial protocol. K Peltzer, D Jones, SM Weiss, et al. BMC Public Health, 11:778doi:10.1186/1471-2458-11-778

Background: Despite the availability of a dual therapy treatment protocol and infant feeding guidelines designed to prevent mother to child transmission (PMTCT) of HIV, of the over 1 million babies born in South Africa each year, only 70% of those born to HIV positive mothers receive dual therapy. Similar to other resource-poor nations facing the integration of PMTCT into routine pregnancy and infant care, efforts in South Africa to scale up PMTCT and reduce transmission to < 5% have fallen far short of the United Nation's goal of 50% reductions in paediatric HIV by 80% coverage of mothers.Methods/Design: This study proposes to evaluate the impact of combining two evidence-based interventions: a couple's risk reduction intervention with an evidence based medication adherence intervention to enhance male participation in combination with improving medication and PMTCT adherence in antenatal clinics to increase PMTCT overall reach and effectiveness. The study will use a group-randomized design, recruiting 240 couples from 12 clinics. Clinics will be randomly assigned to experimental and control conditions and effectiveness of the combined intervention to enhance PMTCT as well as reduce antenatal seroconversion by both individuals and clinics will be examined.Discussion: Shared intervention elements may decrease sexual risk and enhance PMTCT uptake, e.g., increased male participation, enhanced communication, HIV counselling and testing, adherence, serostatus disclosure, suggest that a combined sexual risk reduction and adherence intervention plus PMTCT can increase male participation, increase couples' communication and encourage adherence to the PMTCT process. The findings will impact public health and will enable the health ministry to formulate policy related to male involvement in PMTCT, which will result in PMTCT.

Skill of Frontline Workers Implementing Integrated Management of Neonatal and Childhood Illness: Experience from a District of West Bengal, India.* AB Biswas, DK Mukhopadhyay, NK Mandal, et al.Journal of Tropical Pediatrics; 57(5): i-ii doi:10.1093/tropej/fmr082, Oct 2011

A cross-sectional study was conducted in Purulia district, West Bengal, India, to assess the skill of 155 frontline workers implementing Integrated Management of Neonatal and Childhood Illness (IMNCI) and the logistic support thereof. The skills of counting respiratory rate, assessing immunization status in both age groups, assessment of breastfeeding in young infants and plotting of weight in a growth chart in case of children aged 2–59 months were acquired by majority of workers. Around two-thirds workers synthesized correct classification and nearly 60% gave appropriate management of at least one subgroup. In 30–40% cases, carers received feeding advices. Around 50% casesheets were complete and timely report submission rate was nearly 70%. Necessary equipments were available with majority of workers except the utensils for preparation of ORS. The supply of essential drugs varied from 33.5 to 71.6%. These findings suggest that IMNCI program offered a scope for capacity-building and infrastructure strengthening of the health system.

Stillbirths in a referral medical college hospital, West Bengal, India: A ten-year review.* R Bhattacharyya, A Pal. Journal of Obstetrics and Gynecology Research, Oct 2011.

Aim: To evaluate the stillbirth rate, its major demographic and obstetric risk factors and its trend in a referral teaching hospital. Material and Methods: A hospital-based cross-sectional retrospective study of stillbirths was done among all deliveries over a decade from January 1999 to December 2008. The stillbirth rate and its changing trends over 10 years were evaluated and its associated risk factors were also assessed. Results: The stillbirth rate in the present study decreased from 44.87 per 1000 total births in 1999–2003 to 24.15 per 1000 total births in 2004–2008. Maternal age over 35 years, pregnant women having parity ≥ 4, lower socioeconomic status and poor antenatal check up were responsible for highest number of stillbirths. Other associated risk factors responsible for stillbirths were antepartum hemorrhage (8.35%), medical diseases of mother (8.00%), severe prematurity (7.34%), birth trauma (3.12%) and intrapartum asphyxia (16.73%). Thirty-six percent of the stillbirths occurred at term and 27% at 34–36 weeks of pregnancy. Only 2% of fetuses had congenital anomalies. Incidence of fresh stillbirth was high. Lower segment cesarean section rate was 16%. Conclusion: Poor antenatal check-up, lower socioeconomic status and weak referral facilities were the major factors responsible for stillbirths. Most of the stillbirths were preventable by improving women's education and compliance to antenatal care. So proper antenatal care, prompt referral services and availability of emergency obstetric care will provide a pivotal role for reduction of stillbirths.

Transfer of newborns to neonatal care unit: a registry based study in Northern Tanzania. BT Mmbaga, RT Lie, GS Kibiki, et al. BMC Pregnancy and Childbirth, 11:68doi:10.1186/1471-2393-11-68, Oct 2011

Background: Reduction in neonatal mortality has been slower than anticipated in many low income countries including Tanzania. Adequate neonatal care may contribute to reduced mortality. We studied factors associated with transfer of babies to a neonatal care unit (NCU) in data from a birth registry at Kilimanjaro Christian Medical Centre (KCMC) in Tanzania. Methods: A total of 21 206 singleton live births registered from 2000 to 2008 were included. Multivariable analysis was carried out to study neonatal transfer to NCU by socio-demographic factors, pregnancy complications and measures of the condition of the newborn. Results: A total of 3190 (15%) newborn singletons were transferred to the NCU. As expected, neonatal transfer was strongly associated with specific conditions of the baby including birth weight above 4000 g (relative risk (RR) = 7.2; 95% confidence interval (CI) 6.5-8.0) or below 1500 g (RR=3.0; 95% CI: 2.3-4.0), five minutes Apgar score less than 7 (RR=4.0; 95% CI: 3.4-4.6), and preterm birth before 34 weeks of gestation (RR=1.8; 95% CI: 1.5-2.1). However, pregnancy- and delivery-related conditions like premature rupture of membrane (RR=2.3; 95% CI: 1.9-2.7), preeclampsia (RR=1.3; 95% CI: 1.1-1.5), other vaginal delivery (RR=2.2; 95% CI: 1.7-2.9) and caesarean section (RR=1.9; 95% CI: 1.8-2.1) were also significantly associated with transfer. Birth to a first born child was associated with increased likelihood of transfer (relative risk (RR) 1.4; 95% CI: 1.2-1.5), while the likelihood was reduced (RR=0.5; 95% CI: 0.3-0.9) when the father had no education.Conclusions: In addition to strong associations between neonatal transfer and classical neonatal risk factors for morbidity and mortality, some pregnancy-related and demographic factors were predictors of neonatal transfer. Overall, transfer was more likely for babies with signs of poor health status or a complicated pregnancy. Except for a possibly reduced use of transfer for babies of non-educated fathers and a high transfer rate for first born babies, there were no signs that transfer was based on non-medical indications.

Type of delivery attendant, place of delivery and risk of early neonatal mortality: analyses of the 1994–2007 Indonesia Demographic and Health Surveys.* CR Titaley, MJ Dibley, CL Roberts. Health Policy and Planning, doi: 10.1093/heapol/czr053; Aug 2011.

 Access to skilled birth attendants and emergency obstetric care are thought to prevent early neonatal deaths. This study aims to examine the association between the type of delivery attendant and place of delivery and early neonatal mortality in Indonesia. Four Indonesia Demographic and Health Surveys from 1994, 1997, 2002/2003 and 2007 were used, including survival information from 52 917 singleton live-born infants of the most recent birth of a mother within a 5-year period before each survey. Cox proportional hazards regression models were used to obtain the hazard ratio for univariable and multivariable analyses. Our study found no significant reduction in the risk of early neonatal death for home deliveries assisted by the trained attendants compared with those assisted by untrained attendants. In rural areas, the risk of early neonatal death was higher for home deliveries assisted by trained attendants than home deliveries assisted by untrained attendants. In urban areas, a protective role of institutional deliveries was found if mothers had delivery complications. However, an increased risk was associated with deliveries in public hospitals in rural areas. Infants of mothers attending antenatal care services were significantly protected against early neonatal deaths, irrespective of the urban or rural setting. An increased risk of early neonatal death was also associated with male infants, infants whose size at birth was smaller than average and/or infants reported to be born early. A reduced risk was observed amongst mothers with high levels of education. Continuous improvement in the skills and the quality of the village midwives might benefit maternal and newborn survival. Efforts to strengthen the referral system and to improve the quality of delivery and newborn care services in health facilities are important, particularly in public hospitals and in rural areas.

User fees and maternity services in Ethiopia.* L Pearson, M Gandhi, K Admasu, et al. International Journal of Gynecology and Obstetrics, In press.

Objectives: To examine user fees for maternity services and how they relate to provision, quality, and use of maternity services in Ethiopia. Methods:  The national assessment of emergency obstetric and newborn care (EmONC) examined user fees for maternity services in 751 health facilities that provided childbirth services in 2008. Results: Overall, only about 6.6% of women gave birth in health facilities. Among facilities that provided delivery care, 68% charged a fee in cash or kind for normal delivery. Health centers should be providing maternity services free of charge (the healthcare financing proclamation), yet 65% still charge for some aspect of care, including drugs and supplies. The average cost for normal and cesarean delivery was US $7.70 and US $51.80, respectively. Nineteen percent of these facilities required payment in advance for treatment of an obstetric emergency. The health facilities that charged user fees had, on average, more delivery beds, deliveries (normal and cesarean), direct obstetric complications treated, and a higher ratio of skilled birth attendants per 1000 deliveries than those that did not charge. The case fatality rate was 3.8% and 7.1% in hospitals that did and did not charge user fees, respectively. Conclusion: Utilization of maternal health services is extremely low in Ethiopia and, although there is a government decree against charging for maternity service, 65% of health centers do charge for some aspects of maternal care. As health facilities are not reimbursed by the government for the costs of maternity services, this loss of revenue may account for the more and better services offered in facilities that continue to charge user fees. User fees are not the only factor that determines utilization in settings where the coverage of maternity services is extremely low. Additional factors include other out-of-pocket payments such as cost of transport and food and lodging for accompanying relatives. It is important to keep quality of care in mind when user fees are under discussion.

Using a GIS to model interventions to strengthen the emergency referral system for maternal and newborn health in Ethiopia.* PE Bailey, EB Keyes, C Parker, et al. International Journal of Gynecology and Obstetrics, In press.

Objectives:  To show how GIS can be used by health planners to make informed decisions about interventions to increase access to emergency services. Methods: A combination of data sources, including the 2008 national Ethiopian baseline assessment for emergency obstetric and newborn care that covered 797 geo-coded health facilities, LandScan population data, and road network data, were used to model referral networks and catchment areas across 2 regions of Ethiopia. STATA and ArcGIS software extensions were used to model different scenarios for strengthening the referral system, defined by the structural inputs of transportation and communication, and upgrading facilities, to compare the increase in access to referral facilities. Results: Approximately 70% of the population of Tigray and Amhara regions is served by facilities that are within a 2-hour transfer time to a hospital with obstetric surgery. By adding vehicles and communication capability, this percentage increased to 83%. In a second scenario, upgrading 7 strategically located facilities changed the configuration of the referral networks, and the percentage increased to 80%. By combining the 2 strategies, 90% of the population would be served by midlevel facilities within 2&#xa0;hours of obstetric surgery. The mean travel time from midlevel facilities to surgical facilities would be reduced from 121 to 64 minutes in the scenario combining the 2 interventions. Conclusions: GIS mapping and modeling enable spatial and temporal analyses critical to understanding the population's access to health services and the emergency referral system. The provision of vehicles and communication and the upgrading of health centers to first level referral hospitals are short- and medium-term strategies that can rapidly increase access to lifesaving services.

What is quality in maternal and neonatal health care?* JH Raven, RJ Tolhurst, S Tang, et al. Midwifery. Published online 24 October 2011, corrected proof.

Objective: to review published papers and reports examining quality of care in maternal and newborn health to identify definitions and models of quality of care. Design: literature review. Search strategy: electronic search of MEDLINE and organisational databases for literature describing definitions and models of quality used in health care and maternal and newborn health care. Relevant papers and reports were reviewed and summarised. Findings: there is no universally accepted definition of quality of care. The multi-faceted nature of quality is widely acknowledged. In the literature quality of care is described: from the perspective of health care providers, managers and patients; dimensions within the health care system; using elements such as safety, effectiveness, patient-centeredness, timeliness, equity and efficiency; and through the provision of care and experience of care. Key conclusions: the importance of ensuring good quality of care for women and newborn babies is well recognised in the literature, however, there is currently no agreed single and comprehensive definition described. Several models were identified, which can be combined to form a comprehensive framework to help define and assess quality of care or lack of quality. Approaches to quality of care that are specifically important for maternal and newborn health were identified and include a rights based approach, adopting care that is evidence-based, consideration of the mother and baby as interdependent and the fact that pregnancy is on the whole a healthy state. Implications for practice: a model of quality of maternal and newborn health care using perspectives, characteristics, dimensions of the system and elements of quality of care specific to maternal and newborn health is proposed, which can be used as a basis for developing quality improvement strategies and activities, and incorporating quality into existing programmes.

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