Research Round-Up: May 2012

Al-Hosni, M., M. Duenas, et al. Probiotics-supplemented feeding in extremely low-birth-weight infants*. Journal of Perinatology (2012) 32, 253–259; doi:10.1038/jp.2011.51

Objective: The objective of this trial was to test whether probiotic-supplemented feeding to extremely low-birth-weight (ELBW) infants will improve growth as determined by decreasing the percentage of infants with weight below the 10th percentile at 34 weeks postmenstrual age (PMA). Other important outcome measures, such as improving feeding tolerance determined by tolerating larger volume of feeding per day and reducing antimicrobial treatment days during the first 28 days from the initiation of feeding supplementation were also evaluated. Study Design: We conducted a multicenter randomized controlled double-blinded clinical study. The probiotics-supplementation (PS) group received Lactobacillus rhamnosus GG and Bifidobacterium infantis added to the first enteral feeding and continued once daily with feedings thereafter until discharge or until 34 weeks (PMA). The control (C) group received unsupplemented feedings. Infant weight and feeding volumes were recorded daily during the first 28 days of study period. Weights were also recorded at 34 weeks PMA. Result: A total of 101 infants were enrolled (PS 50 versus C 51). There was no difference between the two groups in the percentage of infants with weight below the 10th percentile at 34 weeks PMA (PS group 58% versus C group 60%, (P value 0.83)) or in the average volume of feeding during 28 days after study entry (PS group 59 ml kg−1 versus C group 71 ml kg−1, (P value 0.11)). Calculated growth velocity was higher in the PS group compared with the C group (14.9 versus 12.6 g per day, (P value 0.05)). Incidences of necrotizing enterocolitis (NEC), as well as mortality were similar between the two groups. Conclusion: Although probiotic-supplemented feedings improve growth velocity in ELBW infants, there was no improvement in the percentage of infants with growth delay at 34 weeks PMA. There were no probiotic-related adverse events reported.

Ameh, C., A. Adegoke, et al. (2012). The impact of emergency obstetric care training in Somaliland, Somalia*. International Journal of Gynecology and Obstetrics. Volume 117, Issue 3, June 2012

Objective: To provide and evaluate in-service training in Life Saving Skills: Emergency Obstetric and Newborn Care in order to improve the availability of emergency obstetric care (EmOC) in Somaliland. Methods: In total, 222 healthcare providers (HCPs) were trained between January 2007 and December 2009. A before after study was conducted using quantitative and qualitative methods to evaluate trainee reaction and change in knowledge, skills, and behavior, in addition to functionality of healthcare facilities, during and immediately after training, and at 3 and 6 months post-training. Results: The HCPs reacted positively to the training, with a significant improvement in 50% of knowledge and 100% of skills modules assessed. The HCPs reported improved confidence in providing EmOC. Basic and comprehensive EmOC healthcare facilities provided 100% of expected signal functions compared with 43% and 56%, respectively, at baseline, with trained midwives performing skills usually performed by medical doctors. Lack of drugs, supplies, medical equipment, and supportive policy were identified as barriers that could contribute to nonuse of new skills and knowledge acquired. Conclusion: The training impacted positively on the availability and quality of EmOC and resulted in up-skilling of midwives.

Barros, A.J.D., C. Ronsmans, et al. Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries*. The Lancet, Volume 379, Issue 9822, Pages 1225 – 1233, 31 March 2012 doi:10.1016/S0140-6736(12)60113-5

Background: Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how inequalities in maternal, newborn, and child health interventions vary by intervention and country. Methods: We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality. Findings: Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals. Interpretation: We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries’ poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent. Funding: Bill & Melinda Gates Foundation, Norad, The World Bank.

Chico, R.M., P. Mayaud, et al. Prevalence of Malaria and Sexually Transmitted and Reproductive Tract Infections in Pregnancy in Sub-Saharan Africa. JAMA. 2012;307(19):2079-2086. doi:10.1001/jama.2012.3428.

Context: Malaria and sexually transmitted infections/reproductive tract infections (STIs/RTIs) in pregnancy are direct and indirect causes of stillbirth, prematurity, low birth weight, and maternal and neonatal morbidity and mortality. Objective: To conduct a systematic review and meta-analysis of malaria and STI/RTI prevalence estimates among pregnant women attending antenatal care facilities in sub-Saharan Africa. Data Sources: PubMed, MEDLINE, EMBASE, the World Health Organization International Clinical Trials Registry, and reference lists were searched for studies reporting malaria, syphilis, Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, or bacterial vaginosis among pregnant women attending antenatal care facilities in sub-Saharan Africa.
Study Selection Included studies were conducted in 1990-2011 with open enrollment. Studies from South Africa, where malaria is no longer endemic, were excluded. Data Extraction: Point prevalence estimates were corrected for diagnostic precision. A random-effects model meta-analysis was applied to produce pooled prevalence estimates. Results A total of 171 studies met inclusion criteria, providing 307 point prevalence estimates for malaria or STIs/RTIs and including a total of 340 904 women. The pooled prevalence estimates (with 95% CIs and number of women with positive diagnosis) among studies in 1990-2011 in East and Southern Africa were as follows: syphilis, 4.5% (3.9%-5.1%; n = 8346 positive diagnoses), N gonorrhoeae, 3.7% (2.8%-4.6%; n = 626), C trachomatis, 6.9% (5.1%-8.6%; n = 350), T vaginalis, 29.1% (20.9%-37.2%; n = 5502), bacterial vaginosis, 50.8% (43.3%-58.4%; n = 4280), peripheral malaria, 32.0% (25.9%-38.0%; n = 11 688), and placental malaria, 25.8% (19.7%-31.9%; n = 1388). West and Central Africa prevalence estimates were as follows: syphilis, 3.5% (1.8%-5.2%; n = 851), N gonorrhoeae, 2.7% (1.7%-3.7%; n = 73), C trachomatis, 6.1% (4.0%-8.3%; n = 357), T vaginalis, 17.8% (12.4%-23.1%; n = 822), bacterial vaginosis, 37.6% (18.0%-57.2%; n = 1208), peripheral malaria, 38.2% (32.3%-44.1%; n = 12 242), and placental malaria, 39.9% (34.2%-45.7%; n = 4658). Conclusion The dual prevalence of malaria and STIs/RTIs in pregnancy among women who attend antenatal care facilities in sub-Saharan Africa is considerable, with the combined prevalence of curable STIs/RTIs being equal to, if not greater than, malaria.

Darlow, B., A. Zin, et al. (2012). Capacity building of nurses providing neonatal care in Rio de Janeiro, Brazil: methods for the POINTS of care project to enhance nursing education and reduce adverse neonatal outcomes. BMC Nursing 11(1): 3.

Background: Increased survival of preterm infants in developing countries has often been accompanied by increased morbidity. A previous study found rates of severe retinopathy of prematurity varied widely between different neonatal units in Rio de Janeiro. Nurses have a key role in the care of high-risk infants but often do not have access to ongoing education programmes. We set out to design a quality improvement project that would provide nurses with the training and tools to decrease neonatal mortality and morbidity. The purpose of this report is to describe the methods and make the teaching package (POINTS of care–six modules addressing Pain control; optimal Oxygenation; Infection control; Nutrition interventions; Temperature control; Supportive care) available to others. Methods: Six neonatal units, caring for 40% of preterm infants in Rio de Janeiro were invited to participate. In Phase 1 of the study multidisciplinary workshops were held in each neonatal unit to identify the neonatal morbidities of interest and to plan for data collection. In Phase 2 the teaching package was developed and tested. Phase 3 consisted of 12 months data collection utilizing a simple tick-sheet for recording. In Phase 4 (the Intervention) all nurses were asked to complete all six modules of the POINTS of care package, which was supplemented by practical demonstrations. Phase 5 consisted of a further 12 months data collection. In Phase 1 it was agreed to include inborn infants with birthweight [less than or equal to] 1500 g or gestational age of [less than or equal to] 34 weeks. The primary outcome was death before discharge and secondary outcomes included retinopathy of prematurity and bronchopulmonary dysplasia. Assuming 400-450 infants in both pre- and post-intervention periods the study had 80% power at p = < 0.05 to detect an increase in survival from 68% to 80%; a reduction in need for supplementary oxygen at 36 weeks post menstrual age from 11% to 5.5% and a reduction in retinopathy of prematurity requiring treatment from 7% to 2.5%. Discussion: The results of the POINTS of Care intervention will be presented in a separate publication.

Duffy, J.L., R.M. Ferguson, et al. Opportunities for Improving, Adapting and Introducing Emollient Therapy and Improved Newborn Skin Care Practices in Africa*. Journal of Tropical Pediatrics, April 2012. 58 (2): 88-95.

Infections and complications from prematurity cause a majority of global neonatal deaths. Recent evidence has demonstrated the life-saving ability of topical emollient therapy in resource-poor settings. With the potential to reduce infection and neonatal mortality by 41 and 26%, respectively, emollient therapy is a promising option for improving newborn care. While application of oil to the newborn is nearly universal in South Asia, little is known about this behavior in Africa. This article draws on literature regarding neonatal skin care in Africa to describe behaviors, motivations and potential for introducing topical emollients. Oil massage does not appear to be universal. When oil massage occurs, substances of unknown toxicity and possibly damaging massage practices are used; thus, there is scope for introduction of improved therapeutic practices. Overall, more research is needed to develop the evidence base of current neonatal skin care behaviors in Africa, and to determine emollient therapy effectiveness there.

Edmonds, J. K., D. Hruschka, et al. (2012). Womens social networks and birth attendant decisions: Application of the Network-Episode Model*. Social Science and Medicine 74(3): 452-459.

This paper examines the association of womens social networks with the use of skilled birth attendants in uncomplicated pregnancy and childbirth in Matlab,  Bangladesh. The Network-Episode Model was applied to determine if network structure variables (density/kinship homogeneity/strength of ties) together with network content (endorsement for or against a particular type of birth attendant) explain the type of birth attendant used by women above and beyond the variance explained by womens individual attributes. Data were collected by interviewing a representative sample of 246 women, 18e45 years of age, using survey and social network methods between October and December 2008. Logistic regression models were used to examine the associations. Results suggest that the structural properties of networks did not add to explanatory value but instead network content or the perceived advice of network members add significantly to the explanation of variation in service use. Testing aggregate network variables at the individual level extends the ability of the individual profile matrix to explain outcomes. Community health education and mobilization interventions attempting to increase demand for skilled attendants need to reflect the centrality of kinship networks to women in Bangladesh and the likelihood of women to heed the advice of their network of advisors with regard to place of birth.

El-Dib, M., A.N. Massaro, et al. Neurobehavioral assessment as a predictor of neurodevelopmental outcome in preterm infants*. Journal of Perinatology (2012) 32, 299–303; doi:10.1038/jp.2011.100.

Objective: Preterm infants are at risk for neurodevelopmental impairment. The Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) is a standardized assessment for the neurobehavioral integrity of the newborn. The use of NNNS as a prognostic tool is still emerging. We hypothesized that the NNNS examination performed at term equivalent can detect neurobehavioral alterations in very low birth weight infants and can help in predicting their neurodevelopmental outcome at 18 months corrected age (CA). Study Design: This is a prospective study that included preterm infants with birth weight <1500 g and gestational age 34 weeks. They were evaluated with NNNS at term-equivalent and 12 summary scores were assigned. Infants who had 2 or more NNNS summary scores that were 2 s.d. beyond the mean of the study group were categorized as having abnormal NNNS. Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) of Bayley Scales of Infant Development (BSID-II) were determined at 18 months CA. Multiple linear regression models were used to examine the predictivity of the NNNS summary scores for both MDI and PDI. Result: A total of 41 infants were evaluated at term and at 18 months CA. The average MDI was 78±15 and the average PDI was 80±14. Significant neurodevelopmental delay was observed in 50% and 31% of infants with abnormal and normal NNNS, respectively. Using multiple linear regression, NNNS was predictive for both MDI (P=0.011, adjusted R 2=0.295) and PDI (P=0.002, adjusted R 2=0.441). Lower MDI was associated with less regulation and more nonoptimal reflexes, whereas lower PDI was associated with less regulation, more nonoptimal reflexes, hypertonicity and handling. Conclusion: NNNS at term-equivalent age can detect neurobehavioral alterations in very low birth weight infants. Individual summary scores showed significant correlation with both the MDI and PDI at 18 months CA.

Gill, C. J., N. G. Guerina, et al. (2012). Training Zambian traditional birth attendants to reduce neonatal mortality in the Lufwanyama Neonatal Survival Project (LUNESP)*. International Journal of Gynecology & Obstetrics.

Objective: To provide relevant details on how interventions in the Lufwanyama Neonatal Survival Project (LUNESP) were developed and how Zambian traditional birth attendants (TBAs) were trained to perform them. Methods: The study tested 2 interventions: a simplified version of the American Academy of Pediatricsu2019 neonatal resuscitation protocol (NRP); and antibiotics with facilitated referral (AFR). Results: Key elements that enabled the positive study result were: focusing on common and correctible causes of mortality; selecting a study population with high unmet public health need; early community mobilization to build awareness and support; emphasizing simplicity in the intervention technology and algorithms; using a traditional training approach appropriate to students with low literacy rates; requiring TBAs to demonstrate their competence before completing each workshop; and minimizing attrition of skills by retraining and reassessing the TBAs regularly throughout the study. Conclusion: An effective NRP training model was created that is suitable for community-based neonatal interventions, in research or programmatic settings, and by practitioners with limited obstetric skills and low rates of literacy.

Guliani, H., A. Sepehri, et al. (2012). What impact does contact with the prenatal care system have on womens use of facility delivery? Evidence from low-income countries*. Social Science and Medicine. Volume 74, Issue 12, June 2012.

Prenatal and delivery care are critical both for maternal and newborn health. Using the Demographic and Health Surveys (DHS) data for thirty-two low-income countries across Asia, sub-Saharan Africa and Latin America, and employing a two-level random-intercept model, this paper empirically assesses the influence of prenatal attendance and a wide array of observed individual-, household- and community-level characteristics on a womans decision to give birth at a health facility or at home. The results show that prenatal attendance does appreciably influence the use of facility delivery in all three geographical regions, with women having four visits being 7.3 times more likely than those with no prenatal care to deliver at a health facility. These variations are more pronounced for Sub-Saharan Africa. The influence of the number of prenatal visits, maternal age and education, parity level, and economic status of the birthing women on the place of delivery is found to vary across the three geographical regions. The results also indicate that obstetrics care is geographically and economically more accessible to urban and rural women from the non-poor households than those from the poor households. The strong influence of number of visits, household wealth, education and regional poverty on the site of delivery setting suggests that policies aimed at increasing the use of obstetric care programs should be linked with the objectives of social development programs such as poverty reduction, enhancing the status of women, and increasing primary and secondary school enrollment rate among girls.

Jamieson, D.J., C.S. Chasela, et al. Maternal and infant antiretroviral regimens to prevent postnatal HIV-1 transmission: 48-week follow-up of the BAN randomised controlled trial*. The Lancet, Early Online Publication, 26 April 2012 doi:10.1016/S0140-6736(12)60321-3

Background: In resource-limited settings where no safe alternative to breastfeeding exists, WHO recommends that antiretroviral prophylaxis be given to either HIV-infected mothers or infants throughout breastfeeding. We assessed the effect of 28 weeks of maternal or infant antiretroviral prophylaxis on postnatal HIV infection at 48 weeks. Methods: The Breastfeeding, Antiretrovirals, and Nutrition (BAN) Study was undertaken in Lilongwe, Malawi, between April 21, 2004, and Jan 28, 2010. 2369 HIV-infected breastfeeding mothers with a CD4 count of 250 cells per μL or more and their newborn babies were randomly assigned with a variable-block design to one of three, 28-week regimens: maternal triple antiretroviral (n=849); daily infant nevirapine (n=852); or control (n=668). Patients and local clinical staff were not masked to treatment allocation, but other study investigators were. All mothers and infants received one dose of nevirapine (mother 200 mg; infant 2 mg/kg) and 7 days of zidovudine (mother 300 mg; infants 2 mg/kg) and lamivudine (mothers 150 mg; infants 4 mg/kg) twice a day. Mothers were advised to wean between 24 weeks and 28 weeks after birth. The primary endpoint was HIV infection by 48 weeks in infants who were not infected at 2 weeks and in all infants randomly assigned with censoring at loss to follow-up. This trial is registered with, number NCT00164736. Findings: 676 mother—infant pairs completed follow-up to 48 weeks or reached an endpoint in the maternal-antiretroviral group, 680 in the infant-nevirapine group, and 542 in the control group. By 32 weeks post partum, 96% of women in the intervention groups and 88% of those in the control group reported no breastfeeding since their 28-week visit. 30 infants in the maternal-antiretroviral group, 25 in the infant-nevirapine group, and 38 in the control group became HIV infected between 2 weeks and 48 weeks of life; 28 (30%) infections occurred after 28 weeks (nine in maternal-antiretroviral, 13 in infant-nevirapine, and six in control groups). The cumulative risk of HIV-1 transmission by 48 weeks was significantly higher in the control group (7%, 95% CI 5—9) than in the maternal-antiretroviral (4%, 3—6; p=0·0273) or the infant-nevirapine (4%, 2—5; p=0·0027) groups. The rate of serious adverse events in infants was significantly higher during 29—48 weeks than during the intervention phase (1·1 [95% CI 1·0—1·2] vs 0·7 [0·7—0·8] per 100 person-weeks; p<0·0001), with increased risk of diarrhoea, malaria, growth faltering, tuberculosis, and death. Nine women died between 2 weeks and 48 weeks post partum (one in maternal-antiretroviral group, two in infant-nevirapine group, six in control group). Interpretation: In resource-limited settings where no suitable alternative to breastfeeding is available, antiretroviral prophylaxis given to mothers or infants might decrease HIV transmission. Weaning at 6 months might increase infant morbidity.

Jefferies, A.L. Kangaroo care for the preterm infant and family. Paediatr Child Health 2012;17(3):141-3

Kangaroo care (KC) is the practice of skin-to-skin contact between infant and parent. In developing countries, KC for low-birthweight infants has been shown to reduce mortality, severe illness, infection and length of hospital stay. KC is also beneficial for preterm infants in high-income countries. Cardiorespiratory and temperature stability, sleep organization and duration of quiet sleep, neurodevelopmental outcomes, breastfeeding and modulation of pain responses appear to be improved for preterm infants who have received KC during their hospital stay. No detrimental effects on physiological stability have been demonstrated for infants as young as 26 weeks’ gestational age, including those on assisted ventilation. Mothers show enhanced attachment behaviours and describe an increased sense of their role as a mother. The practice of KC should be encouraged in nurseries that care for preterm infants. Information is available to assist in developing guidelines and protocols.

Kattenberg, J.H., C.M. Tahita, et al. Antigen persistence of rapid diagnostic tests in pregnant women in Nanoro, Burkina Faso, and the implications for the diagnosis of malaria in pregnancy*. Tropical Medicine & International Health. Volume 17, Issue 5, pages 550–557, May 2012

Objectives: To evaluate persistence of several Plasmodium antigens in pregnant women after treatment and compare diagnostics during treatment follow-up. Methods: Thirty-two pregnant women (N = 32) with confirmed malaria infection by a histidine-rich protein 2 (HRP2)-based rapid diagnostic test (RDT) and microscopy were followed for 28 days after artemisinin-based combination therapy (ACT). A Plasmodium lactate dehydrogenase (pLDH)-based RDT and two ELISAs based on the detection of dihydrofolate reductase–thymidylate synthase (DHFR-TS) and haeme detoxification protein (HDP) were compared with each other and to RT-PCR at each visit. Results: The mean visit number (95% confidence interval) on which the HRP2-based RDT was still positive after treatment was 3.4 (2.7–4.1) visits with some patients still positive at day 28. This is significantly later than the pLDH-based RDT [0.84 (0.55–1.1)], microscopy (median 1, range 1–3), DHFR-TS-ELISA [1.7 (1.1–2.3)] and RT-PCR (median 2, range 1–5) (P < 0.05), but not significantly later than HDP-ELISA [2.1 (1.6–2.7)]. Lower gravidity and higher parasite density at day 0 resulted in significantly longer positive results with most tests (P < 0.05). Conclusions: HRP2 can persist up to 28 days after ACT treatment; therefore, this test is not suitable for treatment follow-up in pregnant women and can generate problems when using this test during intermittent preventive treatment (IPTp). DHFR-TS is less persistent than HRP2, making it a potentially interesting target for diagnosis.

Liu, L., H.L. Johnson, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000*. The Lancet, Early Online Publication, 11 May 2012. doi:10.1016/S0140-6736(12)60560-1

Background: Information about the distribution of causes of and time trends for child mortality should be periodically updated. We report the latest estimates of causes of child mortality in 2010 with time trends since 2000. Methods: Updated total numbers of deaths in children aged 0—27 days and 1—59 months were applied to the corresponding country-specific distribution of deaths by cause. We did the following to derive the number of deaths in children aged 1—59 months: we used vital registration data for countries with an adequate vital registration system; we applied a multinomial logistic regression model to vital registration data for low-mortality countries without adequate vital registration; we used a similar multinomial logistic regression with verbal autopsy data for high-mortality countries; for India and China, we developed national models. We aggregated country results to generate regional and global estimates. Findings: Of 7·6 million deaths in children younger than 5 years in 2010, 64·0% (4·879 million) were attributable to infectious causes and 40·3% (3·072 million) occurred in neonates. Preterm birth complications (14·1%; 1·078 million, uncertainty range [UR] 0·916—1·325), intrapartum-related complications (9·4%; 0·717 million, 0·610—0·876), and sepsis or meningitis (5·2%; 0·393 million, 0·252—0·552) were the leading causes of neonatal death. In older children, pneumonia (14·1%; 1·071 million, 0·977—1·176), diarrhoea (9·9%; 0·751 million, 0·538—1·031), and malaria (7·4%; 0·564 million, 0·432—0·709) claimed the most lives. Despite tremendous efforts to identify relevant data, the causes of only 2·7% (0·205 million) of deaths in children younger than 5 years were medically certified in 2010. Between 2000 and 2010, the global burden of deaths in children younger than 5 years decreased by 2 million, of which pneumonia, measles, and diarrhoea contributed the most to the overall reduction (0·451 million [0·339—0·547], 0·363 million [0·283—0·419], and 0·359 million [0·215—0·476], respectively). However, only tetanus, measles, AIDS, and malaria (in Africa) decreased at an annual rate sufficient to attain the Millennium Development Goal 4. Interpretation: Child survival strategies should direct resources toward the leading causes of child mortality, with attention focusing on infectious and neonatal causes. More rapid decreases from 2010—15 will need accelerated reduction for the most common causes of death, notably pneumonia and preterm birth complications. Continued efforts to gather high-quality data and enhance estimation methods are essential for the improvement of future estimates. Funding: The Bill & Melinda Gates Foundation.

Lunze, K., D.H. Hamer. Thermal protection of the newborn in resource-limited environments*. Journal of Perinatology (2012) 32, 317–324; doi:10.1038/jp.2012.11; published online 1 March 2012

Appropriate thermal protection of the newborn prevents hypothermia and its associated burden of morbidity and mortality. Yet, current global birth practices tend to not adequately address this challenge. Here, we discuss the pathophysiology of hypothermia in the newborn, its prevention and therapeutic options with particular attention to resource-limited environments. Newborns are equipped with sophisticated mechanisms of body temperature regulation. Neonatal thermoregulation is a critical function for newborn survival, regulated in the hypothalamus and mediated by endocrine pathways. Hypothermia activates cellular metabolism through shivering and non-shivering thermogenesis. In newborns, optimal temperature ranges are narrow and thermoregulatory mechanisms easily overwhelmed, particularly in premature and low-birth weight infants. Hyperthermia most commonly is associated with dehydration and potentially sepsis. The lack of thermal protection promptly leads to hypothermia, which is associated with detrimental metabolic and other pathophysiological processes. Simple thermal protection strategies are feasible at community and institutional levels in resource-limited environments. Appropriate interventions include skin-to-skin care, breastfeeding and protective clothing or devices. Due to poor provider training and limited awareness of the problem, appropriate thermal care of the newborn is often neglected in many settings. Education and appropriate devices might foster improved hypothermia management through mothers, birth attendants and health care workers. Integration of relatively simple thermal protection interventions into existing mother and child health programs can effectively prevent newborn hypothermia even in resource-limited environments.

Miller, P. C., G. Rashida, et al. The effect of traditional birth attendant training on maternal and neonatal care*. International Journal of Gynecology and Obstetrics. Volume 117, Issue 2, May 2012.

Objective: To determine whether traditional birth attendants (TBAs) trained via the SMART Dai method were superior to untrained TBAs in knowledge and practice regarding maternal and newborn care. Methods: In a cluster-randomized trial in the Dera Ghazi Khan District of Punjab, Pakistan, 120 rural communities each with a population of approximately 5000 were randomly assigned to a community-based intervention (CBI) or a health systems intervention (HSI). In the CBI communities, 288 TBAs underwent an innovative 8-day training course on maternal and newborn care, initially evaluated by pre- and post-tests. After an average of 19months post-training, 277 TBAs, together with 257 comparably chosen untrained TBAs from the HSI communities, were tested and interviewed. Patients from both referred and non-referred deliveries were also interviewed. Results: Characteristics of TBAs in the two groups were similar. The TBAs were evaluated according to various measures of knowledge, skill, and practice (including referral), with patient reports on practice compared with TBA reports. By most measures, trained TBAs outperformed untrained ones, often to significant degrees. Conclusion: SMART Dai training seemed to be an important factor in the significant reduction in perinatal mortality in the CBI areas. Properly trained TBAs can substantially contribute to improved delivery outcomes.

Namiiro, F., J. Mugalu, et al. Poor birth weight recovery among low birth weight/preterm infants following hospital discharge in Kampala, Uganda.  BMC Pregnancy and Childbirth 12(1): 1.

Background: Healthy infants typically regain their birth weight by 21 days of age; however, failure to do so may be due to medical, nutritional or environmental factors. Globally, the incidence of low birth weight deliveries is high, but few studies have assessed the postnatal weight changes in this category of infants, especially in Africa. The aim was to determine what proportion of LBW infants had not regained their birth weight by 21 days of age after discharge from the Special Care Unit of Mulago hospital, Kampala. Methods: A cross sectional study was conducted assessing weight recovery of 235 LBW infants attending the Kangaroo Clinic in the Special Care Unit of Mulago Hospital between January and April 2010. Infants aged 21 days with a documented birth weight and whose mothers gave consent to participate were included in the study. Baseline information was collected on demographic characteristics, history on pregnancy, delivery and postnatal outcome through interviews. Pertinent infant information like gestation age, diagnosis and management was obtained from the medical records and summarized in the case report forms. Results: Of the 235 LBW infants, 113 (48.1%) had not regained their birth weight by 21 days. Duration of hospitalization for more than 7 days (AOR: 4.2; 95% CI: 2.3 – 7.6; p value < 0.001) and initiation of the first feed after 48 hours (AOR: 1.9; 95% CI 1.1 – 3.4 p value 0.034) were independently associated with failure to regain birth weight. Maternal factors and the infant’s physical examination findings were not significantly associated with failure to regain birth weight by 21 days of age. Conclusion: Failure to regain birth weight among LBW infants by 21 days of age is a common problem in Mulago Hospital occurring in almost half of the neonates attending the Kangaroo clinic. Currently, the burden of morbidity in this group of high-risk infants is undetected and unaddressed in many developing countries. Measures for consideration to improve care of these infants would include; discharge after regaining birth weight and use of total parenteral nutrition. However, due to the pressure of space, keeping the baby and mother is not feasible at the moment hence the need for a strong community system to boost care of the infant. Close networking with support groups within the child’s environment could help alleviate this problem.

Obare, F., C. Warren, et al. Community-level impact of the reproductive health vouchers programme on service utilization in Kenya. Health Policy and Planning 2012;1–11. doi:10.1093/heapol/czs033

This paper examines community-level association between exposure to the reproductive health vouchers programme in Kenya and utilization of services. The data are from a household survey conducted among 2527 women (15–49 years) from voucher and comparable non-voucher sites. Analysis entails cross-tabulations with Chi-square tests and significant tests of proportions as well as estimation of multi-level logit models to predict service utilization by exposure to the programme. The results show that for births occurring after the voucher programme began, women from communities that had been exposed to the programme since 2006 were significantly more likely to have delivered at a health facility and to have received skilled care during delivery compared with those from communities that had not been exposed to the programme at all. There were, however, no significant differences in the timing of first trimester utilization of antenatal care (ANC) and making four or more ANC visits by exposure to the programme. In addition, poor women were significantly less likely to have used safe motherhood services (health facility delivery, skilled delivery care and postnatal care) compared with their non-poor counterparts regardless of exposure to the programme. Nonetheless, a significantly higher proportion of poor women from communities that had been exposed to the programme since 2006 used the services compared with their poor counterparts from communities that had not been exposed to the programme at all. The findings suggest that the programme is associated with increased health facility deliveries and skilled delivery care especially among poor women. However, it has had limited community-level impact on the first trimester timing of antenatal care use and making four or more visits, which remain a challenge despite the high proportion of women in the country that make at least one antenatal care visit during pregnancy.

Vais, A. and L. Kean (2012). Stillbirth: is it a preventable public health problem in the 21st century?*Obstetrics, Gynaecology and Reproductive Medicine 22(5): 129-134.

The grief of stillbirth continues to affect a large number of parents in the 21st century. The causes vary throughout the world, with the most prominent being fetal growth restriction, fetal abnormalities, pre-existing maternal medical conditions and infections. Worldwide, as some causes are becoming less prevalent, new causes are emerging, for example maternal obesity. This article reviews the aetiology of stillbirth and attempts to explain the apparent plateauing of stillbirth numbers. Suggestions are made for ways of reducing these rates in various settings throughout the world. Addressing lifestyle factors and the obesity epidemic as well as more effective screening for growth restriction are two interventions.

Vergnano, S., E. Fottrell, et al. Adaptation of a probabilistic method (InterVA) of verbal autopsy to improve the interpretation of cause of stillbirth and neonatal death in Malawi, Nepal, and Zimbabwe. Population Health Metrics 9(1): 48.

Background: Verbal autopsy (VA) is a widely used method for analyzing cause of death in absence of vital registration systems. We adapted the InterVA method to extrapolate causes of death for stillbirths and neonatal deaths from verbal autopsy questionnaires, using data from Malawi, Zimbabwe, and Nepal. Methods: We obtained 734 stillbirth and neonatal VAs from recent community studies in rural areas: 169 from Malawi, 385 from Nepal, and 180 from Zimbabwe. Initial refinement of the InterVA model was based on 100 physician-reviewed VAs from Malawi. InterVA indicators and matrix probabilities for cause of death were reviewed for clinical and epidemiological coherence by a pediatrician-researcher and an epidemiologist involved in the development of InterVA. The modified InterVA model was evaluated by comparing population-level cause-specific mortality fractions and individual agreement from two methods of interpretation (physician review and InterVA) for a further 69 VAs from Malawi, 385 from Nepal, and 180 from Zimbabwe. Results: Case-by-case agreement between InterVA and reviewing physician diagnoses for 69 cases from Malawi, 180 cases from Zimbabwe, and 385 cases from Nepal were 83% (kappa 0.76 (0.75 – 0.80)), 71% (kappa 0.41(0.32-0.51)), and 74% (kappa 0.63 (0.60-0.63)), respectively. The proportion of stillbirths identified as fresh or macerated by the different methods of VA interpretation was similar in all three settings. Comparing across countries, the modified InterVA method found that proportions of preterm births and deaths due to infection were higher in Zimbabwe (44%) than in Malawi (28%) or Nepal (20%). Conclusion: The modified InterVA method provides plausible results for stillbirths and newborn deaths, broadly comparable to physician review but with the advantage of internal consistency. The method allows standardized cross-country comparisons and eliminates the inconsistencies of physician review in such comparisons.

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