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V. Adjiwanou, T. LeGrand. Does Antenatal Care Matter in the Use of Skilled Birth Attendance in Rural Africa: A Multi-country Analysis. Social Science & Medicine. (March, 2013)

While the importance of antenatal care for maternal and child health continues to be debated, several researchers have documented its impact on intermediate variables affecting survival such as birth weight. These studies have also highlighted the problems of causality that are typically not taken into account when estimating the effects of antenatal care on skilled birth attendance. In this study, we revisit this relation in the rural areas of four countries: Ghana, Kenya, Uganda and Tanzania. Using a structural equation modeling approach that corrects for endogeneity, in all four countries we find that the usual simpler probit (or logit) models tend to underestimate the direct effect of antenatal care on skilled birth attendance. Furthermore, in two of the countries, this estimated effect is mediated by the range of services offered to women during antenatal care. These results suggest that governments and NGOs should place more importance on the role of antenatal care providers and on the services they offer, in efforts to promote skilled birth attendance.

L. Alkema, V. Kantorova, C. Menozzi et, al. National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis. The Lancet (March, 2013)

Background: Expansion of access to contraception and reduction of unmet need for family planning are key components to improve reproductive health, but scarce data and variability in data sources create difficulties in monitoring of progress for these outcomes. We estimated and projected indicators of contraceptive prevalence and unmet need for family planning from 1990 to 2015. Methods: We obtained data from nationally representative surveys, for women aged 15—49 years who were married or in a union. Estimates were based on 930 observations of contraceptive prevalence between 1950 and 2011 from 194 countries or areas, and 306 observations of unmet need for family planning from 111 countries or areas. We used a Bayesian hierarchical model combined with country-specific time trends to yield estimates of these indicators and uncertainty assessments. The model accounted for differences by data source, sample population, and contraceptive methods included in the measure. Findings: Worldwide, contraceptive prevalence increased from 54·8% (95% uncertainty interval 52·3—57·1) in 1990, to 63·3% (60·4—66·0) in 2010, and unmet need for family planning decreased from 15·4% (14·1—16·9) in 1990, to 12·3% (10·9—13·9) in 2010. Almost all subregions, except for those where contraceptive prevalence was already high in 1990, had an increase in contraceptive prevalence and a decrease in unmet need for family planning between 1990 and 2010, although the pace of change over time varied between countries and subregions. In 2010, 146 million (130—166 million) women worldwide aged 15—49 years who were married or in a union had an unmet need for family planning. The absolute number of married women who either use contraception or who have an unmet need for family planning is projected to grow from 900 million (876—922 million) in 2010 to 962 million (927—992 million) in 2015, and will increase in most developing countries. Interpretation: Trends in contraceptive prevalence and unmet need for family planning, and the projected growth in the number of potential contraceptive users indicate that increased investment is necessary to meet demand for contraceptive methods and improve reproductive health worldwide. Funding: United Nations Population Division and National University of Singapore.

*K. Edmond. Improving the Quality of Health Facility Care for Neonates in Low- and Middle-income Countries. Journal of Tropical Pediatrics. (March, 2013)

The neonatal period (1–28 days) encompasses the newborn’s transition to independent extra-uterine life. Rapid adaptations in immune, physiological and biochemical functioning occur during this time, as the infant is exposed to multiple environmental influences. The infant is most vulnerable and dependent during these weeks, and this is also a critical period for postnatal intervention and nutritional programming [1]. There has been slow improvement in rates of neonatal mortality despite major reductions in overall child mortality in low- and middle-income countries. Just <4 million infants die each year before reaching 1 month of age, and neonatal deaths now account for 38% of the 10.9 million deaths among children aged <5 years [2]. Tackling neonatal mortality is essential if the fourth millennium development goal to reduce by 2015 overall child mortality by two-thirds from its levels in 1990 is to be achieved. Neonatal mortality rates are likely to remain static at just >40% for the period to 2015 unless there are significant changes in child health interventions and policies. The lack of progress in reducing neonatal mortality is largely because of the difficulties in reducing early neonatal mortality rates.

S. Hodgins, Y.  Pradhan, L. Khana et, al. Chlorhexidine for umbilical cord care: game-changer for newborn survival? Global Health Science and Practice. (March, 2013)

Newborn mortality has been a persistent challenge, with reductions in neonatal deaths lagging behind declines in post-neonatal child mortality in most low-income countries.1 Indeed, until a decade ago, it was widely assumed that we would see marked improvements only with gains in socioeconomic status and substantially strengthened health systems. However, the landmark work of Abhay Bang in the 1990s in a poor area of India with high newborn mortality demonstrated that simple services, delivered in the home by community health workers, could reduce neonatal mortality substantially.2 This prompted new interest in applying the kind of simple primary health care strategies that have been so effective in driving down mortality in older infants and children to the problem of newborn mortality.

*T. Hoehn, Z. Lukac, M. Stehn, E. Mayatepek, et, al. Establishment of the First Newborn Screening Program in the People’s Democratic Republic of Laos. Journal of Tropical Medicine (March, 2013)

Objectives: The People’s Democratic Republic of Laos belongs to the minority of countries worldwide without an established newborn bloodspot screening (NBS) system. Methods: In 2008, we initiated a pilot project of a neonatal screening system in the delivery suites of the Laotian capital, Vientiane. Samples were analysed for thyrotropin-stimulating hormone and 17-hydroxyprogesterone. Results: Altogether 11 362 samples were taken; an initially high recall rate dropped eventually to just above 4%. Two cases of hypothyroidism and one case of congenital adrenal hyperplasia were identified and received timely treatment. Conclusions: In summary, we have demonstrated the feasibility of establishing an NBS system in a low-resource setting as prevalent in Laos. Obstacles for the establishment of a general NBS covering the whole country include the question of financial cover, treatment costs, and adequate teaching and supervision of technicians and doctors.

T. Houweling, P. Tripathy, et al. The equity impact of participatory women’s groups to reduce neonatal mortality in India: secondary analysis of a cluster-randomised trial. International Journal of Epidemiology. (March, 2013)

Progress towards the Millennium Development Goals (MDGs) has been uneven. Inequalities in child health are large and effective interventions rarely reach the most in need. Little is known about how to reduce these inequalities. We describe and explain the equity impact of a women’s group intervention in India that strongly reduced the neonatal mortality rate (NMR) in a cluster-randomised trial. We conducted secondary analyses of the trial data, obtained through prospective surveillance of a population of 228 186. The intervention effects were estimated separately, through random effects logistic regression, for the most and less socio-economically marginalised groups. Among the most marginalised, the NMR was 59% lower in intervention than in control clusters in years 2 and 3 (70%, year 3); among the less marginalised, the NMR was 36% lower (35%, year 3). The intervention effect was stronger among the most than among the less marginalised (P-value for difference = 0.028, years 2-3; P-value for difference = 0.009, year 3). The stronger effect was concentrated in winter, particularly for early NMR. There was no effect on the use of health-care services in either group, and improvements in home care were comparable. Participatory community interventions can substantially reduce socio-economic inequalities in neonatal mortality and contribute to an equitable achievement of the unfinished MDG agenda.

*M. Lango, A. Horn and M. Harrison. Growth Velocity of Extremely Low Birth Weight Preterms at a Tertiary Neonatal Unit in South Africa. Journal of Tropical Pediatrics (March, 2013) 

Introduction: There is wide variation in the feeding practices of extreme low birth weight (ELBW) preterms often guided by tradition and resources. The feeding regimen at Groote Schuur Hospital (GSH) nursery, a tertiary neonatal unit, follows a restricted use of parenteral nutrition and concentrates on early introduction of breast milk. There is a need to determine whether this approach achieves acceptable growth velocity. Objectives: This study aims to describe the growth velocity of ELBW babies at GSH. Design: This was a retrospective cohort study. Methodology: Infant hospital records of all ELBW babies born at GSH from 1 March to 31 August 2010 were accessed from a previously collected database and relevant data extracted. Growth data were collected from birth to 8 weeks postnatal age or discharge, whichever came first. Results: Ninety-one ELBW babies were born during the study period. Forty were excluded from the study. Thirty died before discharge, and 10 were excluded for other reasons. The mean (SD) gestation of the cohort was 28.5 (1.6) weeks, and the median (range) birth weight was 875 (640–995) g. The overall mean (SD) growth velocity was 14 (2.9) g/kg/day. There was no statistically significant association between the growth velocity and the type of feed given, days to establishing full enteral feeds, time to regaining birth weight, HIV exposure status, intra-uterine growth restriction or exposure to antenatal steroids. Conclusion: In our cohort of ELBW infants, growth velocity was within the range currently deemed acceptable by international consensus.

*D. Lawlor, A. Wills, A. Fraser et, al. Association of maternal vitamin D status during pregnancy with bone-mineral content in offspring: a prospective cohort study. The Lancet (March, 2013)

Background: Maternal vitamin D status in pregnancy is a suggested determinant of bone-mineral content (BMC) in offspring, but has been assessed in small studies. We investigated this association in a large prospective study. Methods: Eligible participants were mother-and-singleton-offspring pairs who had participated in the Avon Longitudinal Study of Parents and Children, and in which the mother had recorded measurements of 25(OH)D concentration in pregnancy and the offspring had undergone dual-energy x-ray absorptiometry at age 9—10 years. 25(OH)D concentrations in pregnancy were assessed per 10·0 nmol/L and classified as sufficient (more than 50·00 nmol/L), insufficient (49·99—27·50 nmol/L), or deficient (lower than 27·50 nmol/L). Associations between maternal serum 25(OH)D concentrations and offspring total body less head (TBLH) and spinal BMC were assessed by trimester. Results: 3960 mother-and-offspring pairs, mainly of white European origin, were assessed (TBLH BMC n=3960, spinal BMC n=3196). Mean offspring age was 9·9 years. 2644 (77%) mothers had sufficient, 1096 (28%) insufficient, and 220 (6%) deficient 25(OH)D concentrations in pregnancy, but TBLH and spinal BMC did not differ between offspring of mothers in the lower two groups versus sufficient 25(OH)D concentration. No associations with offspring BMC were found for any trimester, including the third trimester, which is thought to be most relevant (TBLH BMC confounder-adjusted mean difference −0·03 g per 10·0 nmol/L, 95% CI −1·71 to 1·65; spinal BMC 0·04 g per 10·0 nmol/L, 95% CI −0·12 to 0·21). Conclusions: We found no relevant association between maternal vitamin D status in pregnancy and offspring BMC in late childhood. Funding: UK Medical Research Council, Welcome Trust, and University of Bristol.

J. Smith, R. Gubin, M. Holston et, al. Misoprostol for postpartum hemorrhage prevention at home birth: an integrative review of global implementation experience to date. BMC Pregnancy and Childbirth. (February, 2013)

Background: Hemorrhage continues to be a leading cause of maternal death in developing countries. The 2012 World Health Organization guidelines for the prevention and management of postpartum hemorrhage (PPH) recommend oral administration of misoprostol by community health workers (CHWs). However, there are several outstanding questions about distribution of misoprostol for PPH prevention at home births. Methods: We conducted an integrative review of published research studies and evaluation reports from programs that distributed misoprostol at the community level for prevention of PPH at home births. We reviewed methods and cadres involved in education of end-users, drug administration, distribution, and coverage, correct and incorrect usage, and serious adverse events. Results: Eighteen programs were identified; only seven reported all data of interest. Programs utilized a range of strategies and timings for distributing misoprostol. Distribution rates were higher when misoprostol was distributed at a home visit during late pregnancy (54.5-96.9%) or at birth (22.5-83.6%), compared to antenatal care (ANC) distribution at any ANC visit (22.5-49.1%) or late ANC visit (21.0-26.7%). Coverage rates were highest when CHWs and traditional birth attendants distributed misoprostol and lower when health workers/ANC providers distributed the medication. The highest distribution and coverage rates were achieved by programs that allowed self-administration. Seven women took misoprostol prior to delivery out of more than 12,000 women who were followed-up. Facility birth rates increased in the three programs for which this information was available. Fifty-one (51) maternal deaths were reported among 86,732 women taking misoprostol: 24 were attributed to perceived PPH; none were directly attributed to use of misoprostol. Even if all deaths were attributable to PPH, the equivalent ratio (59 maternal deaths/100,000 live births) is substantially lower than the reported maternal mortality ratio in any of these countries. Conclusions: Community-based programs for prevention of PPH at home birth using misoprostol can achieve high distribution and use of the medication, using diverse program strategies. Coverage was greatest when misoprostol was distributed by community health agents at home visits. Programs appear to be safe, with an extremely low rate of ante- or intrapartum administration of the medication.

J. Turan, A. Hatcher, J. Medema-Wijnveen et, al. The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya: A Prospective Mixed-Methods Study. PLoS Medicine (March, 2013)

Background: Childbirth with a skilled attendant is crucial for preventing maternal mortality and is an important opportunity for prevention of mother-to-child transmission of HIV. The Maternity in Migori and AIDS Stigma Study (MAMAS Study) is a prospective mixed-methods investigation conducted in a high HIV prevalence area in rural Kenya, in which we examined the role of women's perceptions of HIV-related stigma during pregnancy in their subsequent utilization of maternity services. Methods and Findings: From 2007–2009, 1,777 pregnant women with unknown HIV status completed an interviewer-administered questionnaire assessing their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal care visit. After the visit, a sub-sample of women was selected for follow-up (all women who tested HIV-positive or were not tested for HIV, and a random sample of HIV-negative women, n = 598); 411 (69%) were located and completed another questionnaire postpartum. Additional qualitative in-depth interviews with community health workers, childbearing women, and family members (n = 48) aided our interpretation of the quantitative findings and highlighted ways in which HIV-related stigma may influence birth decisions. Qualitative data revealed that health facility birth is commonly viewed as most appropriate for women with pregnancy complications, such as HIV. Thus, women delivering at health facilities face the risk of being labeled as HIV-positive in the community. Our quantitative data revealed that women with higher perceptions of HIV-related stigma (specifically those who held negative attitudes about persons living with HIV) at baseline were subsequently less likely to deliver in a health facility with a skilled attendant, even after adjusting for other known predictors of health facility delivery (adjusted odds ratio = 0.44, 95% CI 0.22–0.88). Conclusions: Our findings point to the urgent need for interventions to reduce HIV-related stigma, not only for improving quality of life among persons living with HIV, but also for better health outcomes among all childbearing women and their families.

*J. Turan, and L. Nyblade. HIV-related Stigma as a Barrier to Achievement of Global PMTCT and Maternal Health Goals: A Review of the Evidence. Springer (March, 2013)

The global community has set goals of virtual elimination of new child HIV infections and 50 percent reduction in HIV-related maternal mortality by the year 2015. Although much progress has been made in expanding prevention of mother-to-child transmission (PMTCT) services, there are serious challenges to these global goals, given low rates of utilization of PMTCT services in many settings. We reviewed the literature from low-income settings to examine how HIV-related stigma affects utilization of the series of steps that women must complete for successful PMTCT. We found that stigma negatively impacts service uptake and adherence at each step of this “PMTCT cascade”. Modeling exercises indicate that these effects are cumulative and therefore significantly affect rates of infant HIV infection. Alongside making clinical services more available, effective, and accessible for pregnant women, there is also a need to integrate stigma-reduction components into PMTCT, maternal, neonatal, and child health services.

*R. Upadhyay, S. Rai and A. Krishnan. Using Three Delays Model to Understand the Social Factors Responsible for Neonatal Deaths in Rural Haryana, India. Journal of Tropical Medicine (March, 2013)

Objective: To investigate causes of and contributors to newborn deaths in rural Haryana using a three delays audit approach. Methods: The study was conducted in 28 villages under the rural field practice area of the Comprehensive Rural Health Services Project, All India Institute of Medical Sciences situated in Ballabgarh, Haryana. Data were collected through house visits and analysed using the three delays model. Results: Of the 50 newborn deaths investigated, 44% occurred within the first 24 h after birth. The leading causes of death were pre-term/low birthweight (32%), birth asphyxia (28%) and neonatal sepsis (14%). Major contributing delays to neonatal death were caretaker’s delay in deciding to seek care (44%, 22/50) and delay in reaching a health care facility, i.e. the transport delay (34%, 17/50). Conclusions: Household and transport-related delays were the major contributors to newborn deaths, and efforts to improve newborn survival need to address both concurrently.

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Photo: The Bill & Melinda Gates Foundation. This blog was originally published in Impatient Optimists. Written by Gary Darmstadt, Cyril Engmann and Wendy Prosser

To mark the critical first 28 days of a newborn’s life–the neonatal period (when a baby is most at risk)– in the lead up to the Global Newborn Health Conference, Gary Darmstadt and others will be sharing, via Twitter, 28 days of “Did You Know?” facts about newborn health. Follow @gdarmsta, share the facts widely using #Newborn2013 and we can work towards saving newborn lives together. 

In talking to new parents of healthy babies in the US, most pediatricians will provide anticipatory guidance. That means advice about feeding their newborn, expected sleeping patterns, number of stools and wet diapers to expect in a day, and how to recognize what may be danger signs in their baby. There is a plethora of materials parents can access:  books, pamphlets, websites, and adverts.  Add to this information volunteered by grandparents and parents, friends and co-workers, and the new, often sleep-deprived parents are surrounded, and often overwhelmed with advice from all corners.

We each take that advice with a grain of salt. And we each know that when our newborn is sick, regardless of what our well-meaning friends suggest, we can always take her to the doctor for professional advice and care.

That’s the scenario in many neighborhoods in high-income countries. Now let’s go to a rural community in South East Asia or West Africa where a newborn baby may be unwell.

There are significant differences.

A large number of newborns continue to be born outside of health facilities, often in the home. The delivery is managed by a non-skilled birth attendant such as an elderly woman from the village; there may have been variable attention given to clean delivery care; the new parents have probably received very little anticipatory guidance from a health professional; and the baby may not have been named or been in any contact with the health or registration system.

On all continents, though, moms, family members and community members probably recognize or sense when a baby is sick—those very subtle signs of fever or sleeping longer than normal or urinating less, or just “feeling that something isn’t quite right”. And these rural community members also give  suggestions of what could be wrong with a newborn, why he is not eating, or why he has breathing troubles They also provide their suggestions of how to treat those illnesses. 

What sort of suggestions do we find?

Some work we have completed in rural Ghana suggests that while mothers and care-givers recognize these “danger signs” of illness, their understanding of the causes and thus the suggestions of how to treat those illnesses may be different and oftentimes based on tradition. For example, rubbing herbs on the mother’s chest will make her milk less “bitter” so the baby will eat more, or making a loud noise in the baby’s ear will help her breathe at birth.

Another difference between these two scenes is that mothers in rural northern Ghana don’t get to take the advice “with a grain of salt.”

Decisions about newborn health care often rest beyond the mothers and instead with the fathers, grandmothers, and mothers-in-law. Grandmothers are often the first to spot problems and then decide how to treat them, either with a traditional approach, a local healer, or, in the case of certain illnesses, a skilled health care worker at a health clinic, although, as another study found, less than half of newborns who were identified as being sick or possibly sick from rural Africa and South East Asia were taken to see any qualified health practitioner.

The findings indicate that even if a mother wants to take her dehydrated baby directly to a health center knowing that would be the best care, she cannot make that decision on her own. 

So what does this mean for those of us working in global health?

As we are preparing for the Global Newborn Health Conference coming up April 15-18, we have to consider the implications of these cultural practices when designing interventions for newborn health. Newborn care must reach beyond the usual boundaries of a health clinic or a focus only on the mother. We must recognize the powerful influence of grandmothers, fathers and traditional healers on newborn care to combine both traditional and formal health care approaches.

Getting advice is inevitable as a new parent. We want to make sure that advice is appropriate – both culturally and technically – and can help save a newborn’s life.