Research Round-Up: September 2011

Birth defects in newborns and stillborns: an example of the Brazilian reality. CIF Oliveira, A Richieri-Costa, VC Carvalho, DC Moz Vaz, AC Fett-Conte. BMC Research Notes, 4:343; September 2011.

Background: This study constitutes a clinical and genetic study of all newborn and stillborn infants with birth defects seen in a period of one year in a medical school hospital located in Brazil. The aims of this study were to estimate the incidence, causes and consequences of the defects. Methods: For all infants we carried out physical assessment, photographic records, analysis of medical records and collection of additional information with the family, besides the karyotypic analysis or molecular tests in indicated cases. Results: The incidence of birth defects was 2.8%. Among them, the etiology was identified in 73.6% (ci95%: 64.4-81.6%). Etiology involving the participation of genetic factors single or associated with environmental factors) was more frequent 94.5%, ci95%: 88.5-98.0%) than those caused exclusively by environmental factors (alcohol in and gestational diabetes mellitus). The conclusive or presumed diagnosis was possible in 85% of the cases. Among them, the isolated congenital heart disease (9.5%) and Down syndrome (9.5%) were the most common, followed by gastroschisis (8.4%), neural tube defects (7.4%) and clubfoot (5.3%). Maternal age, parental consanguinity, exposure to teratogenic agents and family susceptibility were some of the identified risk factors. The most common observed consequences were prolonged hospital stays and death. Conclusions: The current incidence of birth defects among newborns and stillbirths of in our population is similar to those obtained by other studies performed in Brazil and in other underdeveloped countries. Birth defects are one of the major causes leading to lost years of potential life. The study of birth defects in underdeveloped countries should continue. The identification of incidence, risk factors and consequences are essential for planning preventive measures and effective treatments.

Clinical Prediction Score for Nasal CPAP Failure in Pre-term VLBW Neonates with Early Onset Respiratory Distress.* MS Pillai, MJ Sankar, K Mani, R Agarwal, VK Paul, AK Deorari. Journal of Tropical Pediatrics; 57 (4): 274-279.

We prospectively observed 62 pre-term very low birth weight neonates initiated on nasal continuous positive airway pressure (CPAP) for respiratory distress in the first 24 h of life to devise a clinical score for predicting its failure. CPAP was administered using short binasal prongs with conventional ventilators. On multivariate analysis, we found three variables—gestation <28 weeks [adjusted odds ratio (OR) 6.5; 95% confidence interval (CI) 1.5–28.3], pre-term premature rupture of membranes [adjusted OR 5.3; CI 1.2–24.5], and product of CPAP pressure and fraction of inspired oxygen ≥1.28 at initiation to maintain saturation between 88% and 93% [adjusted OR 3.9; CI 1.0–15.5] to be independently predictive of failure. A prediction model was devised using weighted scores of these three variables and lack of exposure to antenatal steroids. The clinical scoring system thus developed had 75% sensitivity and 70% specificity for prediction of CPAP failure (area under curve: 0.83; 95% CI 0.71–0.94).

Difficulties leaving home: a cross-sectional study of delays in seeking emergency obstetric care in Herat, Afghanistan.* A Hirose, M Borchert, et al. Social Science & Medicine; In Press, Corrected Proof.

This study used an analytical cross-sectional design to identify risk factors associated with delays in care-seeking among women admitted in life-threatening conditions to a maternity hospital in Herat, Afghanistan, from February 2007 to January 2008. Disease-specific criteria of “near-miss” were used to identify women in life-threatening conditions. Among 472 eligible women and their husbands, 411 paired interviews were conducted, and information on socio-demographic factors; the woman's status and social resources; the husband's social networks; health care accessibility and utilisation; care-seeking costs; and community characteristics were obtained. Decision and departure delays were assessed quantitatively from reported timings of symptom recognition, care-seeking decision, and departure for health facilities. Censored normal regression analyses suggest that although determinants of decision delay were influenced by the nature and symptoms of complications, uptake of antenatal care (ANC) and the birth plan reduced decision delay at the time of the obstetric emergency. Access to care and social networks reduced departure delay. Programmatic efforts may be directed towards exploiting the roles of ANC and social resources in facilitating access to emergency obstetric care.

Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis.* S Hawkes, N Matin, N Broutet, N Low. The Lancet Infectious Diseases, Volume 11, Issue 9, Pages 684 - 691, September 2011.

Background: About 2·1 million pregnant women have active syphilis every year. Without screening and treatment, 69% of these women will have an adverse outcome of pregnancy. The objectives of this study were to review the literature systematically to determine the effectiveness of screening interventions to prevent congenital syphilis and other adverse pregnancy outcomes. Methods: We searched four electronic databases and selected studies to examine evidence for effectiveness of interventions on three outcomes: increased uptake of syphilis testing, increased treatment rates, and reduction in adverse pregnancy outcomes. We used fixed effects meta-analysis to estimate pooled relative risks if no or little evidence of heterogeneity between trials existed. Findings: Ten studies met the inclusion criteria, including two randomised trials. Only two studies aimed to encourage women to seek care earlier in pregnancy. Nine studies included decentralisation of screening and treatment. The effects of the interventions on uptake of testing for antenatal syphilis and receiving at least one dose of penicillin were variable and could not be combined statistically. Study interventions were associated with a reduction in perinatal death (pooled risk ratio [RR] from three studies 0·46, 95% CI 0·26—0·82) and stillbirth (pooled RR from three studies 0·42, 95% CI 0·19—0·93). The incidence of congenital syphilis was reduced in all four studies that measured this outcome with heterogeneous results. Interpretation: Interventions to improve the coverage and effect of screening programmes for antenatal syphilis could reduce the syphilis-attributable incidence of stillbirth and perinatal death by 50%. The resources required to roll out antenatal screening programmes would be a worthwhile investment for reduction of adverse pregnancy outcomes and improvement of neonatal and child survival.

Emergency obstetric care availability: a critical assessment of the current indicator.* S Gabrysch, P Zanger, et al. (2011). Tropical Medicine & International Health. August 2011.

Monitoring progress in reducing maternal and perinatal mortality requires suitable indicators. The density of emergency obstetric care (EmOC) facilities has been proposed as a potentially useful indicator, but different UN documents make inconsistent recommendations, and its current formulation is not associated with maternal mortality. We compiled recently published indicator benchmarks and distinguished three sources of inconsistency: (i) use of different denominator metrics (per birth and per population), (ii) different assumptions on need for EmOC and for EmOC facilities and (iii) failure to specify facility capacity (birth load). The UN guidelines and handbook require fewer EmOC facilities than the World Health Report 2005 and do not specify capacity for deliveries or staffing levels. We recommend (i) always using births as the denominator for EmOC facility density, (ii) clearly stating assumptions on the proportion of deliveries needing basic and comprehensive emergency obstetric care and the desired proportion of deliveries in EmOC facilities and (iii) specifying facility capacity and staffing and adapting benchmarks for settings with different population density to ensure geographical accessibility.

Neonatal Mortality Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities. MZ Oestergaard, M Inoue, S Yoshida, et al. PLoS Medicine  8(8).

Background: Historically, the main focus of studies of childhood mortality has been the infant and under-five mortality rates. Neonatal mortality (deaths ,28 days of age) has received limited attention, although such deaths account for about 41% of all child deaths. To better assess progress, we developed annual estimates for neonatal mortality rates (NMRs) and neonatal deaths for 193 countries for the period 1990–2009 with forecasts into the future. Methods and Findings: We compiled a database of mortality in neonates and children (,5 years) comprising 3,551 countryyears of information. Reliable civil registration data from 1990 to 2009 were available for 38 countries. A statistical model was developed to estimate NMRs for the remaining 155 countries, 17 of which had no national data. Country consultation was undertaken to identify data inputs and review estimates. In 2009, an estimated 3.3 million babies died in the first month of life— compared with 4.6 million neonatal deaths in 1990—and more than half of all neonatal deaths occurred in five countries of the world (44% of global livebirths): India 27.8% (19.6% of global livebirths), Nigeria 7.2% (4.5%), Pakistan 6.9% (4.0%), China 6.4% (13.4%), and Democratic Republic of the Congo 4.6% (2.1%). Between 1990 and 2009, the global NMR declined by 28% from 33.2 deaths per 1,000 livebirths to 23.9. The proportion of child deaths that are in the neonatal period increased in all regions of the world, and globally is now 41%. While NMRs were halved in some regions of the world, Africa’s NMR only dropped 17.6% (43.5 to 35.9). Conclusions: Neonatal mortality has declined in all world regions. Progress has been slowest in the regions with high NMRs. Global health programs need to address neonatal deaths more effectively if Millennium Development Goal 4 (two-thirds reduction in child mortality) is to be achieved.

Obstetrician and Nurse–Midwife Collaboration: Successful Public Health and Private Practice Partnership.* J Shaw-Battista, A Fineberg, et al. (2011). Obstetrics & Gynecology 118(3): 663-672.

Objective: To evaluate maternal and neonatal outcomes of collaborative maternity care for a socioeconomically diverse patient population in a California community hospital. Methods: Collaborative practice structure and clinical guidelines were analyzed, as were de-identified electronic medical records for all primiparous women who delivered term singletons between 2000 and 2010 (N=4,426). Demographics, care processes, and perinatal outcomes were compared among women seen prenatally in a private collaborative practice compared with a Federally Qualified Health Center prenatal clinic run by nurse–midwives. Results: Evidence-based practices were used to achieve excellent perinatal outcomes. Three quarters of women received intrapartum nurse–midwifery care (74.4%). Few differences were seen in management or outcomes among women from different prenatal clinics despite significant variation in demographic and clinical characteristics. Private practice patients were older, less likely to be obese, and more likely to speak English compared with counterparts from public health clinics. They were also more likely to use hydrotherapy or epidural analgesia, or experience severe perineal laceration and repair. Overall, pharmacologic pain relief methods were limited: less than a quarter of primiparous women used narcotics (21.2%), epidural analgesia (23.7%), or warm water immersion (23.2%). Labor induction and augmentation, and cesarean delivery rates (12.5%), were similar among groups and low overall. Conclusion: A collaborative practice of low-tech, high-touch care results in high-quality maternity services. The care model holds promise for replication to address health disparities by limiting obstetric interventions and warrants further investigation with regard to associated costs and resultant outcomes.

Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method. H Kalter, R Salgado, et al. (2011). Population Health Metrics 9(1): 45.

"Social autopsy" refers to an interview process aimed at identifying social, behavioral, and health systems contributors to maternal and child deaths. It is often combined with a verbal autopsy interview to establish the biological cause of death. Two complementary purposes of social autopsy include providing population-level data to health care programmers and policymakers to utilize in developing more effective strategies for delivering maternal and child health care technologies, and increasing awareness of maternal and child death as preventable problems in order to empower communities to participate and engage health programs to increase their responsiveness and accountability. Through a comprehensive review of the literature, this paper examines the concept and development of social autopsy, focusing on the contributions of the Pathway Analysis format for child deaths and the Maternal and Perinatal Death Inquiry and Response program in India to social autopsy's success in meeting key objectives. The Pathway Analysis social autopsy format, based on the Pathway to Survival model designed to support the Integrated Management of Childhood Illness approach, was developed from 1995 to 2001 and has been utilized in studies in Asia, Africa, and Latin America. Adoption of the Pathway model has enriched the data gathered on care seeking for child illnesses and supported the development of demand- and supply-side interventions. The instrument has recently been updated to improve the assessment of neonatal deaths and is soon to be utilized in large-scale population-representative verbal/social autopsy studies in several African countries. Maternal death audit, starting with confidential inquiries into maternal deaths in Britain more than 50 years ago, is a long-accepted strategy for reducing maternal mortality. More recently, maternal social autopsy studies that supported health programming have been conducted in several developing countries. From 2005 to 2009, 10 high-mortality states in India conducted community-based maternal verbal/social autopsies with participatory data sharing with communities and health programs that resulted in the implementation of numerous data-driven maternal health interventions. Social autopsy is a powerful tool with the demonstrated ability to raise awareness, provide evidence in the form of actionable data and increase motivation at all levels to take appropriate and effective actions. Further development of the methodology along with standardized instruments and supporting tools are needed to promote its wide-scale adoption and use.

The development and application of a new tool to assess the adequacy of the content and timing of antenatal care. K Beeckman , R Louckx , G Masuy-Stroobant , S Downe, K Putman. BMC Health Services Research, 11:213doi:10.1186/1472-6963-11-213, September 2011.

Background: Current measures of antenatal care use are limited to initiation of care and number of visits. This study aimed to describe the development and application of a tool to assess the adequacy of the content and timing of antenatal care. Method: The Content and Timing of care in Pregnancy (CTP) tool was developed based on clinical relevance for ongoing antenatal care and recommendations in national and international guidelines. The tool reflects minimal care recommended in every pregnancy, regardless of parity or risk status. CTP measures timing of initiation of care, content of care (number of blood pressure readings, blood tests and ultrasound scans) and whether the interventions were received at an appropriate time. Antenatal care trajectories for 333 pregnant women were then described using a standard tool (the APNCU index), that measures the quantity of care only, and the new CTP tool. Both tools categorise care into 4 categories, from 'Inadequate' (both tools) to 'Adequate plus' (APNCU) or 'Appropriate' (CTP). Participants recorded the timing and content of their antenatal care prospectively using diaries. Analysis included an examination of similarities and differences in categorisation of care episodes between the tools. Results: According to the CTP tool, the care trajectory of 10,2% of the women was classified as inadequate, 8,4% as intermediate, 36% as sufficient and 45,3% as appropriate. The assessment of quality of care differed significantly between the two tools. Seventeen care trajectories classified as 'Adequate' or 'Adequate plus' by the APNCU were deemed 'Inadequate' by the CTP. This suggests that, despite a high number of visits, these women did not receive the minimal recommended content and timing of care. Conclusions: The CTP tool provides a more detailed assessment of the adequacy of antenatal care than the current standard index. However, guidelines for the content of antenatal care vary, and the tool does not at the moment grade over-use of interventions as 'Inappropriate'. Further work needs to be done to refine the content items prior to larger scale testing of the impact of the new measure.

The role of faith-based organizations in maternal and newborn health care in Africa.* M Widmer, AP Betran, et al. (2011). International Journal of Gynecology & Obstetrics 114(3): 218-222.

Background: Global disparities in maternal and newborn health represent one of the starkest health inequities of our times. Faith-based organizations (FBOs) have historically played an important role in providing maternal/newborn health services in African countries. However, the contribution of FBOs in service delivery is insufficiently recognized and mapped. Objectives: A systematic review of the literature to assess available evidence on the role of FBOs in the area of maternal/newborn health care in Africa. Search strategy MEDLINE and EMBASE were searched for articles published between 1989 and 2009 on maternal/newborn health and FBOs in Africa. Results Six articles met the criteria for inclusion. These articles provided information on 6 different African countries. Maternal/newborn health services provided by FBOs were similar to those offered by governments, but the quality of care received and the satisfaction were reported to be better. Conclusion: Efforts to document and analyze the contribution of FBOs in maternal/newborn health are necessary to increase the recognition of FBOs and to establish stronger partnerships with them in Africa as an untapped route to achieving Millennium Development Goals 4 and 5.

Why do families of sick newborns accept hospital care? A community-based cohort study in Karachi, Pakistan.* A Owais, S Sultana, A D Stein, N H Bashir, R Awaldad and A K M Zaidi. Journal of Perinatology. September 2011.

Objective: Sick young infants are at high risk of mortality in developing countries, but families often decline hospital referral. Our objective was to identify the predictors of acceptance of referral for hospital care among families of severely ill newborns and infants <59 days old in three low-income communities of Karachi, Pakistan. Study Design: A cohort of 541 newborns and infants referred from home by community health workers conducting household surveillance, and diagnosed with a serious illness at local community clinics between 1 January and 31 December 2007, was followed-up within 1 month of referral to the public hospital. Results: Only 24% of families accepted hospital referral. Major reasons for refusal were financial difficulties (67%) and father/elder denying permission (65%). Religious/cultural beliefs were cited by 20% of families. Referral acceptance was higher with recognition of severity of the illness by mother (odds ratio=12.7; 95%confidence interval=4.6 to 35.2), family's ability to speak the dominant language at hospital (odds ratio=2.0; 95% confidence interval=1.3-3.1), presence of grunting in the infant (odds ratio=3.3; 95% confidence interval=1.2-9.0) and infant temperature <35.5 °C (odds ratio=4.1; 95% confidence interval=2.3 to 7.4). No gender differential was observed. Conclusion: Refusal of hospital referral for sick young infants is very common. Interventions that encourage appropriate care seeking, as well as community-based management of young infant illnesses when referral is not feasible are needed to improve neonatal survival in low-income countries.

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