Newborn health research published in December and January 2013-2014.

Part 1! Research Round-Up: January 2014

The past two months were packed with excellent publications and research on newborn health. This is just Part 1 (Authors A – M) of what HNN has compiled. Take a look at Part 2 (N – Z) by clicking here

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Background: Mother-to-child transmission (MTCT) of HIV infection remains a major public health problem and constitutes the most important cause of HIV infection in children under the age of 15 years old. Awareness on MTCT of HIV and knowledge of its timing usually pose a direct effect on utilization of PMTCT services (mainly HIV testing, infant feeding options and antiretroviral use). The objective of this study is to assess pregnant women’s knowledge on timing of MTCT of HIV in Southern Ethiopia.
Methods: A cross sectional study was conducted in 62 health centers in Southern Ethiopia from February 25 to March 24, 2012. A total of 1325 antenatal care attending women were included in the survey by using a multistage sampling technique. Data were collected using a structured and pre-tested questionnaire. Multiple logistic regression analysis was employed to identify variables associated with women’s knowledge on timing of MTCT of HIV.
Results: All interviewed pregnant women were aware of HIV/AIDS transmission, but only 60.7% were aware of the risk of MTCT. The possibility of MTCT during pregnancy, delivery and breastfeeding was known by 48.4%, 58.6% and 40.7% of the respondents, respectively. The proportion of women who were fully knowledgeable on timing of MTCT was 11.5%. Women’s full knowledge on timing of MTCT was associated with maternal education [AOR = 3.68, 95% CI: 1.49-9.08], and being government employee [AOR = 2.50, 95% CI: 1.23- 5.07]. Whereas, there was a negative association between full knowledge of women on timing of MTCT and no offer of information on MTCT/PMTCT by antenatal care (ANC) service provider [AOR = 0.44, 95% CI: 0.30-0.64], lack of discussion on ANC with male partner [AOR = 0.30, 95% CI: 0.12-0.72], and lack of discussion on HIV/AIDS with male partner [AOR = 0.17, 95% CI: 0.07-0.43].
Conclusion: There was low awareness and knowledge on timing of MTCT of HIV in this study. Hence, strengthening the level of PMTCT services in ANC settings and devising mechanisms to promote involvement of men in PMTCT services is needed.
Z. Bhutta, R. Black. Global Maternal, Newborn, and Child Health — So Near and Yet So Far. The New England Journal of Medicine. (December, 2013).
A little more than 13 years ago, world leaders assembled in New York to sign the Millennium Declaration to address some of the greatest moral dilemmas of our times — unequal global health, poverty, and inequities in development — and to establish a set of interrelated goals and targets to be met by 2015. Key goals included the Millennium Development Goal (MDG) 4 targeting a reduction in mortality among children younger than 5 years of age by two thirds and MDG 5 targeting a reduction in maternal mortality by three quarters, both from 1990 base figures. With less than 3 years to go, despite overall global progress, these two MDGs are seriously off target for many countries.1
Recent assessment of global statistics suggests that despite major gains, among the 75 so-called Countdown countries that have 98% of all maternal deaths and deaths among children younger than 5 years of age, only 17 are on track to reach the MDG 4 target for child mortality and only 9 are on track to reach the MDG 5 target for maternal mortality.2 However, estimates from the Institute for Health Metrics and Evaluation suggest that 31 countries will achieve MDG 4, 13 countries will achieve MDG 5, and only 9 countries will achieve both targets.3 As we celebrate the fact that the annual number of deaths among children younger than 5 years of age has fallen to 6.6 million (uncertainty range, 6.3 to 7.0 million), which is a 48% reduction from the 12.6 million deaths (uncertainty range, 12.4 to 12.9 million) in 1990, despite an increased number of births in many high-burden countries during the same time period,4 the sobering realization is that even in countries that will reach their MDG 4 and 5 targets, many will still have high numbers of deaths, with much scope for improvement.
B. Choulagai, S. Onta, N. Subedi, et al. Barriers to using skilled birth attendants’ services in mid- and far-western Nepal: a cross-sectional study. BMC International Health & Human Rights (December, 2013).
Background: Skilled birth attendants (SBAs) provide important interventions that improve maternal and neonatal health and reduce maternal and neonatal mortality. However, utilization and coverage of services by SBAs remain poor, especially in rural and remote areas of Nepal. This study examined the characteristics associated with utilization of SBA services in mid- and far-western Nepal.
Methods: This cross-sectional study examined three rural and remote districts of mid- and far-western Nepal (i.e., Kanchanpur, Dailekh and Bajhang), representing three ecological zones (southern plains [Tarai], hill and mountain, respectively) with low utilization of services by SBAs. Enumerators assisted a total of 2,481 women. All respondents had delivered a baby within the past 12 months. We used bivariate and multivariate analyses to assess the association between antenatal and delivery care visits and the women’s background characteristics.
Results: Fifty-seven percent of study participants had completed at least four antenatal care visits and 48% delivered their babies with the assistance of SBAs. Knowing the danger signs of pregnancy and delivery (e.g., premature labor, prolonged labor, breech delivery, postpartum hemorrhage, severe headache) associated positively with four or more antenatal care visits (OR = 1.71; 95% CI: 1.41-2.07). Living less than 30 min from a health facility associated positively with increased use of both antenatal care (OR = 1.44; 95% CI: 1.18-1.77) and delivery services (OR = 1.25; CI: 1.03-1.52). Four or more antenatal care visits was a determining factor for the utilization of SBAs.
Conclusions: Less than half of the women in our study delivered babies with the aid of SBAs, indicating a need to increase utilization of such services in rural and remote areas of Nepal. Distance from health facilities and inadequate transportation pose major barriers to the utilization of SBAs. Providing women with transportation funds before they go to a facility for delivery and managing transportation options will increase service utilization. Moreover, SBA utilization associates positively with women’s knowledge of pregnancy danger signs, wealth quintile, and completed antenatal care visits. Nepal’s health system must develop strategies that generate demand for SBAs and also reduce financial, geographic and cultural barriers to such services.
*S. Crede, G. Van der Merwe, J. Hutchinson, et al. Where do pulse oximeter probes break? Journal of Clinical Monitoring and Computing (December, 2013).
Pulse oximetry, a non-invasive method for accurate assessment of blood oxygen saturation (SPO2), is an important monitoring tool in health care facilities. However, it is often not available in many low-resource settings, due to expense, overly sophisticated design, a lack of organised procurement systems and inadequate medical device management and maintenance structures. Furthermore medical devices are often fragile and not designed to withstand the conditions of low-resource settings. In order to design a probe, better suited to the needs of health care facilities in low-resource settings this study aimed to document the site and nature of pulse oximeter probe breakages in a range of different probe designs in a low to middle income country. A retrospective review of job cards relating to the assessment and repair of damaged or faulty pulse oximeter probes was conducted at a medical device repair company based in Cape Town, South Africa, specializing in pulse oximeter probe repairs. 1,840 job cards relating to the assessment and repair of pulse oximeter probes were reviewed. 60.2 % of probes sent for assessment were finger-clip probes. For all probes, excluding the neonatal wrap probes, the most common point of failure was the probe wiring (>50 %). The neonatal wrap most commonly failed at the strap (51.5 %). The total cost for quoting on the broken pulse oximeter probes and for the subsequent repair of devices, excluding replacement components, amounted to an estimated ZAR 738,810 (USD $98,508). Improving the probe wiring would increase the life span of pulse oximeter probes. Increasing the life span of probes will make pulse oximetry more affordable and accessible. This is of high priority in low-resource settings where frequent repair or replacement of probes is unaffordable or impossible.
*E. Duysburgh, M. Ye, A. Williams, et al. Counselling on and women’s awareness of pregnancy danger signs in selected rural health facilities in Burkina Faso, Ghana and Tanzania. Tropical medicine & International Health (December, 2013).
Objective: The aims of this study were to (i) assess healthcare workers’ counselling practices concerning danger signs during antenatal consultations in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania; to (ii) assess pregnant women’s awareness of these danger signs; and (iii) to identify factors affecting counselling practices and women’s awareness.
Methods: Cross-sectional study in rural PHC facilities in Burkina Faso, Ghana and Tanzania. In each country, 12 facilities were randomly selected. WHO guidelines were used as standard for good counselling. We assessed providers’ counselling practice on seven danger signs through direct observation study (35 observations/facility). Exit interviews (63 interviews/facility) were used to assess women’s awareness of the same seven danger signs. We used negative binomial regression to assess associations with health services’ and socio-demographic characteristics and to estimate per study site the average number of danger signs on which counselling was provided and the average number of danger signs mentioned by women.
Results: About one in three women was not informed of any danger sign. For most danger signs, fewer than half of the women were counselled. Vaginal bleeding and severe abdominal pain were the signs most counselled on (between 52% and 66%). At study facilities in Burkina Faso, 58% of the pregnant women were not able to mention a danger sign, in Ghana this was 22% and in Tanzania 30%. Fever, vaginal bleeding and severe abdominal pain were the danger signs most frequently mentioned. The type of health worker (depending on the training they received) was significantly associated with counselling practices. Depending on the study site, characteristics significantly associated with awareness of signs were women’s age, gestational age, gravidity and educational level.
Conclusion: Counselling practice is poor and not very efficient. A new approach of informing pregnant women on danger signs is needed. However, as effects of antenatal care education remain largely unknown, it is very well possible that improved counselling will not affect maternal and newborn mortality and morbidity.
Background: Maternal–newborn contact enhances organization of the infant’s physiological systems, including stress reactivity, autonomic functioning, and sleep patterns, and supports maturation of the prefrontal cortex and its ensuing effects on cognitive and behavioral control. Premature birth disrupts brain development and is associated with maternal separation and disturbances of contact-sensitive systems. However, it is unknown whether the provision of maternal–preterm contact can improve long-term functioning of these systems.
Methods: We used the Kangaroo Care (KC) intervention and provided maternal–newborn skin-to-skin contact to 73 premature infants for 14 consecutive days compared with 73 case-matched control subjects receiving standard incubator care. Children were then followed seven times across the first decade of life and multiple physiologic, cognitive, parental mental health, and mother–child relational measures were assessed.
Results: KC increased autonomic functioning (respiratory sinus arrhythmia, RSA) and maternal attachment behavior in the postpartum period, reduced maternal anxiety, and enhanced child cognitive development and executive functions from 6 months to 10 years. By 10 years of age, children receiving KC showed attenuated stress response, improved RSA, organized sleep, and better cognitive control. RSA and maternal behavior were dynamically interrelated over time, leading to improved physiology, executive functions, and mother–child reciprocity at 10 years.
Conclusions: These findings are the first to demonstrate long-term effects of early touch-based intervention on children’s physiologic organization and behavioral control and have salient implications for the care practices of premature infants. Results demonstrate the dynamic cascades of child physiological regulation and parental provisions in shaping developmental outcome and may inform the construction of more targeted early interventions.
K. Fortner, C. Grotegut, C. Ransom, et al. Bacteria Localization and Chorion Thinning among Preterm Premature Rupture of Membranes. PLoS One (January, 2014).
Objective: Bacterial colonization of the fetal membranes and its role in pathogenesis of membrane rupture is poorly understood. Prior retrospective work revealed chorion layer thinning in preterm premature rupture of membranes (PPROM) subjects. Our objective was to prospectively examine fetal membrane chorion thinning and to correlate to bacterial presence in PPROM, preterm, and term subjects.
Study Design: Paired membrane samples (membrane rupture and membrane distant) were prospectively collected from: PPROM = 14, preterm labor (PTL = 8), preterm no labor (PTNL = 8), term labor (TL = 10), and term no labor (TNL = 8), subjects. Sections were probed with cytokeratin to identify fetal trophoblast layer of the chorion using immunohistochemistry. Fluorescence in situ hybridization was performed using broad range 16 s ribosomal RNA probe. Images were evaluated, chorion and choriodecidua were measured, and bacterial fluorescence scored. Chorion thinning and bacterial presence were compared among and between groups using Student’s t-test, linear mixed effect model, and Poisson regression model (SAS Cary, NC).
Results: In all groups, the fetal chorion cellular layer was thinner at rupture compared to distant site (147.2 vs. 253.7 µm, p<0.0001). Further, chorion thinning was greatest among PPROM subjects compared to all other groups combined, regardless of site sampled [PPROM(114.9) vs. PTL(246.0) vs. PTNL(200.8) vs. TL(217.9) vs. TNL(246.5)]. Bacteria counts were highest among PPROM subjects compared to all other groups regardless of site sampled or histologic infection [PPROM(31) vs. PTL(9) vs. PTNL(7) vs. TL(7) vs. TNL(6)]. Among all subjects at both sites, bacterial counts were inversely correlated with chorion thinning, even excluding histologic chorioamnionitis (p<0.0001 and p = 0.05).
Conclusions: Fetal chorion was uniformly thinner at rupture site compared to distant sites. In PPROM fetal chorion, we demonstrated pronounced global thinning. Although cause or consequence is uncertain, bacterial presence is greatest and inversely correlated with chorion thinning among PPROM subjects.
*T. Govender, H. Coovadia. Eliminating mother to child transmission of HIV-1 and keeping mothers alive: Recent progress. The Journal of Infection (January, 2014).
The elimination of new HIV infections in infants and children is part of a broader global commitment by the United Nations. Prevention of Mother to Child transmission (PMTCT) programmes have prevented 350,000 new HIV infections with the use of antiretroviral therapy (ARVs) for pregnant women who are HIV infected, and the majority of these gains were in sub-Saharan Africa. Coverage of PMTCT programmes throughout Africa is variable resulting in many women not having access to the appropriate interventions in the antenatal care setting to prevent vertical transmission. The global elimination target requires a 90% reduction of new child infections and to decrease MTCT to <5% which potentially can be achieved utilising the four pronged approach proposed by the World Health Organization. Family planning messages and provision of contraception methods to avoid unplanned pregnancies are shown to be more effective than HIV Counselling and Testing [HCT] and single dose Nevirapine in averting transmission of perinatal HIV infection. Child survival goes beyond HIV-free survival and safe breastfeeding prevents 13% of deaths under 5 years of age rendering it essential to reduce under-5 mortality. Health systems strengthening to deliver more complex regimens either for prevention purposes or the mothers own health is an important part of a broader continuum of interventions which will depend on the effective delivery of current treatment modalities, development of new prevention interventions including a vaccine, and include prevention of unplanned pregnancies and primary prevention of HIV infections in the mother.
*J. Iams. Prevention of Preterm Parturition. The New England Journal of Medicine (January, 2014).
This article reviews risk factors for preterm delivery, with special attention to previous preterm birth and a short cervix. Strategies for minimizing the risk of preterm birth among high-risk women, including progesterone supplementation and cerclage, are discussed.
A. Iwamoto, N. Seward, A. Prost, et al. Maternal infection and risk of intrapartum death: a population based observational study in South Asia. BioMed Central (December, 2013).
Background: Approximately 1.2 million stillbirths occur in the intrapartum period, and a further 717,000 annual neonatal deaths are caused by intrapartum events, most of which occur in resource poor settings. We aim to test the ‘double-hit’ hypothesis that maternal infection in the perinatal period predisposes to neurodevelopmental sequelae from an intrapartum asphyxia insult, increasing the likelihood of an early neonatal death compared with asphyxia alone. This is an observational study of singleton newborn infants with signs of intrapartum asphyxia that uses data from three previously conducted cluster randomized controlled trials taking place in rural Bangladesh and India.
Methods: From a population of 81,778 births in 54 community clusters in rural Bangladesh and India, we applied mixed effects logistic regression to data on 3890 singleton infants who had signs of intrapartum asphyxia, of whom 769 (20%) died in the early neonatal period. Poor infant condition at five minutes post-delivery was our proxy measure of intrapartum asphyxia. We had data for two markers of maternal infection: fever up to three days prior to labour, and prolonged rupture of membranes (PROM). Cause-specific verbal autopsy data were used to validate our findings using previously mentioned mixed effect logistic regression methods and the outcome of a neonatal death due to intrapartum asphyxia.
Results: Signs of maternal infection as indicated by PROM, combined with intrapartum asphyxia, increased the risk of an early neonatal death relative to intrapartum asphyxia alone (adjusted odds ratio (AOR) 1.28, 95% CI 1.03 – 1.59). Results from cause-specific verbal autopsy data verified our findings where there was a significantly increased odds of a early neonatal death due to intrapartum asphyxia in newborns exposed to both PROM and intrapartum asphyxia (AOR: 1.52, 95% CI 1.15 – 2.02).
Conclusions: Our data support the double-hit hypothesis for signs of maternal infection as indicated by PROM. Interventions for pregnant women with signs of infection, to prevent early neonatal deaths and disability due to asphyxia, should be investigated further in resource-poor populations where the chances of maternal infection are high.
S. Lund, B. Nielsen, M. Hemed, et al. Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial. BioMed Central (January, 2014).
Background: Applying mobile phones in healthcare is increasingly prioritized to strengthen healthcare systems. Antenatal care has the potential to reduce maternal morbidity and improve newborns’ survival but this benefit may not be realized in sub-Saharan Africa where the attendance and quality of care is declining. We evaluated the association between a mobile phone intervention and antenatal care in a resource-limited setting. We aimed to assess antenatal care in a comprehensive way taking into consideration utilisation of antenatal care as well as content and timing of interventions during pregnancy.
Methods: This study was an open label pragmatic cluster-randomised controlled trial with primary healthcare facilities in Zanzibar as the unit of randomisation. 2550 pregnant women (1311 interventions and 1239 controls) who attended antenatal care at selected primary healthcare facilities were included at their first antenatal care visit and followed until 42 days after delivery. 24 primary health care facilities in six districts were randomized to either mobile phone intervention or standard care. The intervention consisted of a mobile phone text-message and voucher component. Primary outcome measure was four or more antenatal care visits during pregnancy. Secondary outcome measures were tetanus vaccination, preventive treatment for malaria, gestational age at last antenatal care visit, and antepartum referral.
Results: The mobile phone intervention was associated with an increase in antenatal care attendance. In the intervention group 44% of the women received four or more antenatal care visits versus 31% in the control group (OR, 2.39; 95% CI, 1.03-5.55). There was a trend towards improved timing and quality of antenatal care services across all secondary outcome measures although not statistically significant.
*K. Markham, H. Walker, C. Lynch, et al. Preterm Birth Rates in a Prematurity Prevention Clinic After Adoption of Progestin Prophylaxis. Obstetrics & Gynecology. (January, 2014).
Objective: To evaluate whether progestin prophylaxis influenced the odds of recurrent spontaneous preterm birth among pregnant women with a previous preterm birth.
Methods: A retrospective cohort study was performed evaluating outcomes of pregnant women with one or more previous preterm births who received prenatal care in a single academic prematurity clinic. Care algorithms were determined and revised by a single supervising physician. Progestin prophylaxis was adopted in 2004 with accelerated access to the first clinic visit adopted in 2008. Rates of preterm birth before 37, 35, and 32 weeks of gestation were compared over time.
Results: One thousand sixty-six women with a history of one or more spontaneous preterm births received care in the prematurity clinic and were delivered between January 1, 1998, and June 30, 2012. The gestational age at initiation of prenatal care declined significantly after adoption of an accelerated appointment process (median of 19.1 weeks before 2003, 16.2 weeks from 2004 to 2007, and 15.2 weeks from 2008 to 2012, P<.01), and progestin use increased from 50.8% in 2004–2007 to 80.3% after 2008 (P<.01). After adjustment for race, smoking, cerclage, and number of prior preterm deliveries, we noted a statistically significant decreased odds of spontaneous preterm birth in years 2008–2012 compared with 1998–2007 before 37 (adjusted odds ratio [OR] 0.75, 95% confidence interval [CI] 0.58–0.97) and 35 (adjusted OR 0.70, 95% CI (.52–0.94) weeks of gestation.
Conclusion: Adoption of prophylactic progestin treatment was associated with a decreased odds of recurrent preterm birth before 37 or 35 weeks of gestation after adoption of an aggressive program to facilitate early initiation of progestin treatment.
Background: Satisfaction is an important indicator of the quality of care during childbirth. Previous research found that a good environment at a health facility can increase the number of deliveries at that facility. In contrast, an unsatisfying childbirth experience could cause postpartum mental disorder. Therefore it is important to measure mothers’ satisfaction with their childbirth experiences. We tested whether the eight-item Client Satisfaction Questionnaire (CSQ-8) provided useful information about satisfaction with childbirth-related care. The government of the Philippines promotes childbirth at health facilities, so we tested the CSQ-8 in the Philippine cities of Ormoc and Palo.
Methods: This was a cross-sectional study. We targeted multigravid mothers whose last baby had been delivered at a hospital (without complications) and whose 2nd-to-last baby had been delivered at a hospital or at home (without complications). We developed versions of the CSQ-8 in Cebuano and Waray, which are two of the six major Filipino languages. Reliability tests and validation tests were done with data from 100 Cebuano-speaking mothers and 106 Waray-speaking mothers.
Results: Both the Cebuano and Waray versions of the CSQ-8 had high coefficients of internal-consistency reliability (greater than 0.80). Both versions were also unidimensional, which is generally consistent with the English CSQ-8 in a mental-health setting. As hypothesized, the scores for data regarding the second-to-last delivery were higher for mothers who had both their second-to-last and their last delivery in a hospital, than for mothers who had their second-to-last delivery at home and their last delivery in a hospital (Cebuano: p < 0.001, rho = 0.51, Waray: p < 0.001, rho = 0.55).
Conclusions: Scores on the CSQ-8 can be used as indices of general satisfaction with childbirth-related services in clinical settings. This study also exemplifies a convenient method for developing versions of the CSQ-8 in more than one language. These versions of the CSQ-8 can now be used to assess mothers’ satisfaction, so that mothers’ opinions can be taken into account in efforts to improve childbirth-related services, which could increase the proportion of deliveries in medical facilities and thus reduce maternal mortality.
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