Research Round-Up: October 2010

Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn. De Brouwere, V., F. Richard, et al. Tropical Medicine & International Health 15(8): 901-909.
The huge majority of the annual 6.3 million perinatal deaths and half a million maternal deaths take place in developing countries and are avoidable. However, most of the interventions aiming at reducing perinatal and maternal deaths need a health care system offering appropriate antenatal care and quality delivery care, including basic and comprehensive emergency obstetric care facilities. To promote the uptake of quality care, there are two possible approaches: influencing the demand and/or the supply of care. Five lessons emerged from experiences. First, it is difficult to obtain robust evidence of the effects of a particular intervention in a context, where they are always associated with other interventions. Second, the interventions tend to have relatively modest short-term impacts, when they address only part of the health system. Third, the long-term effects of an intervention on the whole health system are uncertain. Fourth, because newborn health is intimately linked with maternal health, it is of paramount importance to organise the continuum of care between mother and newborn. Finally, the transfer of experiences is delicate, and an intervention package that has proved to have a positive effect in one setting may have very different effects in other settings.

Barriers to Formal Emergency Obstetric Care Services’ Utilization. Essendi, H., S. Mills, et al. Journal of Urban Health, 1-14.*
Access to appropriate health care including skilled birth attendance at delivery and timely referrals to emergency obstetric care services can greatly reduce maternal deaths and disabilities, yet women in sub-Saharan Africa continue to face limited access to skilled delivery services. This study relies on qualitative data collected from residents of two slums in Nairobi, Kenya in 2006 to investigate views surrounding barriers to the uptake of formal obstetric services. Data indicate that slum dwellers prefer formal to informal obstetric services. However, their efforts to utilize formal emergency obstetric care services are constrained by various factors including ineffective health decision making at the family level, inadequate transport facilities to formal care facilities and insecurity at night, high cost of health services, and inhospitable formal service providers and poorly equipped health facilities in the slums. As a result, a majority of slum dwellers opt for delivery services offered by traditional birth attendants (TBAs) who lack essential skills and equipment, thereby increasing the risk of death and disability. Based on these findings, we maintain that urban poor women face barriers to access of formal obstetric services at family, community, and health facility levels, and efforts to reduce maternal morbidity and mortality among the urban poor must tackle the barriers, which operate at these different levels to hinder women’s access to formal obstetric care services. We recommend continuous community education on symptoms of complications related to pregnancy and timely referral. A focus on training of health personnel on public relations could also restore confidence in the health-care system with this populace. Further, we recommend improving the health facilities in the slums, improving the services provided by TBAs through capacity building as well as involving TBAs in referral processes to make access to services timely. Measures can also be put in place to enhance security in the slums at night.

High Mortality Rates for Very Low Birth Weight Infants in Developing Countries Despite Training. CA Waldemar, SS Goudar, I Jehan, et al. Pediatrics, October 2010.*
Objective: The goal was to determine the effect of training in newborn care and resuscitation on 7-day (early) neonatal mortality rates for very low birth weight (VLBW) infants. The study was designed to test the hypothesis that these training programs would reduce neonatal mortality rates for VLBW infants. Methods: Local instructors trained birth attendants from 96 rural communities in 6 developing countries in protocol and data collection, the World Health Organization Essential Newborn Care (ENC) course, and a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (NRP), by using a train-the-trainer model. To test the impact of ENC training, data on infants of 500 to 1499 g were collected by using a before/after, active baseline, controlled study design. A cluster-randomized, controlled trial design was used to test the impact of the NRP. Results: A total of 1096 VLBW (500–1499 g) infants were enrolled, and 98.5% of live-born infants were monitored to 7 days. All-cause, 7-day neonatal mortality, stillbirth, and perinatal mortality rates were not affected by ENC or NRP training. Conclusions: Neither ENC nor NRP training of birth attendants decreased 7-day neonatal, stillbirth, or perinatal mortality rates for VLBW infants born at home or at first-level facilities. Encouragement of delivery in a facility where a higher level of care is available may be preferable when delivery of a VLBW infant is expected.

Kangaroo Care on Premature Infant Growth and Maternal Attachment and Post-partum Depression in South Korea. HY Ahn, J Lee, HJ Shin. Journal of Tropical Pediatrics, 56 (5): 342-344, October 2010.*
After births, premature infants need a high level of medical treatments for their survivals in the neonatal intensive care unit (NICU). This separation deprives mothers of the chance to initiate an attachment process. Kangaroo care (KC) can be one of the ways to reunite mothers and their infants in the NICU and improve health outcomes. This study was conducted to investigate the effects of KC on both premature infants and their mothers. Ten sessions of 60-min KC for 3 weeks were practiced at a level III NICU at E university hospital. Infants’ body weight, height and head circumference (HC), maternal attachment and depression were measured. As a result, premature infants in KC showed higher in their height and bigger in their HC than infants in control. Maternal attachment scores were higher among the KC mothers. The results supported the beneficial effects of KC on Korean premature infants and their mothers.

Measuring newborn foot length to identify small babies in need of extra care: a cross sectional hospital based study with community follow-up in Tanzania. T Marchant, J Jaribu, S Penfold, et al. BMC Public Health, 2010, 10:624, 19 October 2010.
Background: Neonatal mortality because of low birth weight or prematurity remains high in many developing country settings. This research aimed to estimate the sensitivity and specificity of newborn foot length to identify babies who are low birth weight or premature and in need of extra care in a rural African setting. Methods: A cross-sectional study of newborn babies in hospital, with community follow-up on the fifth day of life, was carried out between 13 July and 16 October 2009 in southern Tanzania. Foot length, birth weight and gestational age were estimated on the first day and foot length remeasured on the fifth day of life. Results: In hospital 529 babies were recruited and measured within 24 hours of birth, 183 of whom were also followed-up at home on the fifth day. Day one foot length <7cm at birth was 75% sensitive (95%CI 36-100) and 99% specific (95%CI 97-99) to identify very small babies (birth weight <1500grams); foot length <8cm had sensitivity and specificity of 87% (95%CI 79-94) and 60% (95%CI 55-64) to identify those with low birth weight (<2500grams), and 93% (95%CI 82-99) and 58% (95%CI 53-62) to identify those born premature (<37 weeks). Mean foot length on the first day was 7.8cm (standard deviation 0.47); the mean difference between first and fifth day foot lengths was 0.1cm (standard deviation 0.3): foot length measured on or before the fifth day of life identified more than three-quarters of babies who were born low birth weight. Conclusion: Measurement of newborn foot length for home births in resource poor settings has the potential to be used by birth attendants, community volunteers or parents as a screening tool to identify low birth weight or premature newborns in order that they can receive targeted interventions for improved survival.

Midwives of India: Missing in action. D Mavalankar, S Raman, K Vora. Midwifery In Press, October 2010.* 
India had well-trained European and indigenous midwives during the time of British rule. The strong midwifery profession lost its importance after independence for various reasons. As a result maternal mortality remains high in India. This paper analyses reasons for the dilution in the midwifery profession, which include amended regulations, lack of social or political priorities, and change in health programme directions. This paper also presents a framework for midwifery-based maternal health services. This analysis shows that there are local as well as internationally supported efforts to improve midwifery in India.

Neonatal near miss approach in the 2005 WHO Global Survey Brazil. C Pileggi, JP Souza, JG Cecatti, A Faúndes. Jornal de Pediatria 86(1): 21-26.
Objectives: To explore the use of the neonatal near miss concept as a tool to evaluate the quality of neonatal care, as 3 million early neonatal deaths occur every year around the world and the majority of these deaths are avoidable and take place in developing countries. Methods: This is a secondary analysis of the 2005 WHO Global Survey on Maternal and Perinatal Health, a crosssectional study, using data from 19 randomly selected Brazilian hospitals. A pragmatic definition of neonatal near miss was developed and tested. Near miss indicators were calculated. Results: Among the 15,169 live born infants included in this analysis, 424 presented at least one of the following conditions: very low birth weight, less than 30 gestational weeks at birth or an Apgar score at the 5th minute of life less than 7. According to the operational definition, these survivors from life-threatening conditions were considered neonatal near miss cases. The early neonatal mortality rate was 8.2/1,000 live births, the neonatal near miss rate was 21.4 neonatal near miss cases/1,000 live births. Substantial variations in the mortality among neonates with life-threatening conditions at birth were observed suggesting intra-hospital quality of care issues. Conclusion: The near miss concept and indicators provided information that could be useful to evaluate the quality of care and set priorities for further assessments and health care improvement for newborn infants.

Newborn Care Training of Midwives and Neonatal and Perinatal Mortality Rates in a Developing Country. AC Waldemar, EM McClure, E Chomba, H Chakraborty, T Hartwell, H Harris, O Lincetto, L Wright. Pediatrics, October 2010. Epub ahead of print.
Objective: This study was designed to test the hypothesis that 2 training programs would reduce incrementally 7-day neonatal mortality rates for low-risk institutional deliveries. Methods: Using a train-the-trainer model, certified research midwives sequentially trained the midwives who performed deliveries in low-risk, first-level, urban, community health clinics in 2cities in Zambia in the protocol and data collection, in the World Health Organization Essential Newborn Care (ENC) course (universal precautions and cleanliness, routine neonatal care,resuscitation, thermoregulation, breastfeeding, kangaroo care, care of small infants, and common illnesses), and in the American Academy of Pediatrics Neonatal Resuscitation Program (in-depthbasic resuscitation). Data were collected during 3 periods, after implementation of each training course. Results: A total of 71 689 neonates were enrolled in the 3 study periods. All-cause, 7-day neonatal mortality rates decreased from 11.5 deaths per 1000 live births to 6.8 deaths per 1000 live births after ENC training (relative risk: 0.59 [95% confidence interval: 0.48–0.77]; P < .001), because of decreases in rates of deaths attributable to birth asphyxia and infection. Perinatalmortality rates but not stillbirth rates decreased. The 7-day neonatal mortality rate was decreased further after Neonatal Resuscitation Program training, after correction for loss to follow-up monitoring. Conclusions: ENC training for midwives reduced 7-day neonatal mortality rates in low-risk clinics. Additional in-depth basic training in neonatal resuscitation may reduce mortality rates further.

Outcome of Low Birth Weight Infants in Diyala Province of Iraq. KA Obaid, DSH Al Azzawi. Journal of Tropical Pediatrics, September 2010.* 
Objectives: To measure birth weight-specific mortality rates in the Diyala Province of Iraq and to determine if the causes of neonatal death could identify interventions needed to reduce neonatal mortality rates. Method: We retrospectively compared the outcome of 196 neonates with birth weight 500–2499 g admitted in 2003 with 252 such neonates admitted in 2009. Results: The mortality rate in very low birth weight infant (VLBWI) increased from 12/80 (15%) in 2003 to 51/152 (33.6%) in 2009, (p = 0.003). In LBWI, 10/116 (8.6%) died in 2003 compared to 33/152 (13%) in 2009 (p = 0.29). Sepsis accounted for 35.2% of deaths in VLBWI and 39% in LBWI, Perinatal depression explained 39.2% of deaths in VLBWI and 24.2% in LBWI. Conclusion: The VLBWI mortality in the Diyala province of Iraq doubled in the last 6 years reaching 33.6% in 2009, LBWI mortality increased by 50% reaching 13%. Sepsis and perinatal depression accounted for at least two-third of the deaths.

Prevention of mother to child transmission of HIV (PMTCT) programme in KwaZulu-Natal, South Africa: an evaluation of PMTCT implementation and integration into routine maternal, child and women’s health services. C Horwood, L Haskins, K Vermaak, et al. Tropical Medicine & International Health, September 2010.*
Objectives: To evaluate prevention of mother to child transmission of HIV (PMTCT) implementation and integration of PMTCT with routine maternal and child health services in two districts of KwaZulu-Natal; to report PMTCT coverage, to compare recorded and reported information, and to describe responsibilities of nurses and lay counselors. Methods: Interviews were conducted with mothers in post-natal wards (PNW) and immunization clinics; antenatal and child health records were reviewed. Interviews were conducted with nurses and lay counselors in primary health care clinics. Results: Eight hundred and eighty-two interviews were conducted with mothers: 398 in PNWs and 484 immunization clinics. During their recent pregnancy, 98.6% women attended antenatal care (ANC); 60.8% attended their first ANC in the third trimester, and 97.3% were tested for HIV. Of 312 mothers reporting themselves HIV positive during ANC, 91.3% received nevirapine, 78.2% had a CD4 count carried out, and 33.1% had a CD4 result recorded. In the immunization clinic, 47.6% HIV-exposed babies had a PCR test, and 47.0% received co-trimoxazole. Of HIV-positive mothers, 42.1% received follow-up care, mainly from lay counselors. In 12/26 clinics, there was a dedicated PMTCT nurse, PCR testing was not offered in 14/26 clinics, and co-trimoxazole was unavailable in 13/26 immunization clinics. Nurses and lay counselors disagreed about their roles and responsibilities, particularly in the post-natal period. Conclusions: There is high coverage of PMTCT interventions during pregnancy and delivery, but follow-up of mothers and infants is poor. Poor integration of PMTCT services into routine care, lack of clarity about health worker roles and poor record keeping create barriers to accessing services post-delivery.

Recent Trends in Maternal, Newborn, and Child Health in Brazil: Progress Toward Millennium Development Goals 4 and 5. FC Barros, A Matijasevich, J Harris Requejo, et al. American Journal of Public Health, Vol 100, No. 10, October 2010.*
We analyzed Brazil’s efforts in reducing child mortality, improving maternal and child health, and reducing socioeconomic and regional inequalities from 1990 through 2007. We compiled and reanalyzed data from several sources, including vital statistics and population-based surveys. We also explored the roles of broad socioeconomic and demographic changes and the introduction of health sector and other reform measures in explaining the improvements observed. Our findings provide compelling evidence that proactive measures to reduce health disparities accompanied by socioeconomic progress can result in measurable improvements in the health of children and mothers in a relatively short interval. Our analysis of Brazil’s successes and remaining challenges to reach and surpass Millennium Development Goals 4 and 5 can provide important lessons for other low- and middle-income countries.

Stillbirths in rural hospitals in the gambia: a cross-sectional retrospective study. A Jammeh, S Vangen, J Sundby. (2010). Obstetrics and Gynecology International 2010.
Objective: We determined the stillbirth rate and associated factors among women who delivered in rural hospitals in The Gambia. Method: A cross-sectional retrospective case review of all deliveries between July and December 2008 was undertaken. Maternity records were reviewed and abstracted of the mother’s demographic characteristics, obstetric complications and fetal outcome. Main Outcome Measure: The stillbirth rate was calculated as deaths per 1000 births. Results: The hospital-based stillbirth rate was high, 156 (95% CI 138-174) per 1000 births. Of the 1,519 deliveries, there were 237 stillbirths of which 137 (57.8%) were fresh. Severe obstetric complication, birth weight <2500 g, caesarean section delivery, and referral from a peripheral health facility were highly significantly associated with higher stillbirth rates, OR = 6.68 (95% CI 3.84-11.62), 4.47 (95% CI 3.04-6.59), 4.35 (95% CI 2.46-7.69), and 3.82 (95% CI 2.24-6.51), respectively. Half (50%) of the women with stillbirths had no antenatal care OR = 4. 46(95% CI 0.84-23.43). Conclusion: We observed an unacceptably high stillbirth rate in this study. As most of the stillbirths were fresh, improved intrapartum care supported by emergency transport services and skilled personnel could positively impact on perinatal outcomes in rural hospitals in The Gambia.

The experience of being a traditional midwife: relationships with skilled birth attendants. E Dietsch. Rural and Remote Health 10(3), September 2010.
Introduction: This article focuses on an unexpected finding of a research project which explored the experience of being a traditional midwife. The unexpected finding was that traditional midwives often perceive skilled (professional) birth attendants to be abusive of both them and the women who are transferred to hospital for emergency obstetric care. Methods: Eighty-four traditional midwives in the Western Province of Kenya were interviewed individually or in groups with a Bukusu/Kiswahili/English-speaking interpreter. Interviews were audiotaped and the English components were transcribed verbatim. Interview transcripts and observations were thematically analysed. Results: A minority of relationships between traditional midwives and skilled birth attendants were based on mutual respect and collaborative practice. However, the majority of encounters with skilled birth attendants were perceived by the traditional midwives to be abusive for them and the women requiring emergency obstetric care. In the interests of improving health outcomes for women and their newborns, interpersonal skills, including maintaining respectful communication and relationships must be a core competency for all caregivers. Providing opportunities for reciprocal learning and strategies to enhance relationships between traditional midwives and skilled birth attendants are recommended. Conclusion: Current global strategies to reduce maternal and newborn mortality by increasing the number of women birthing with a skilled (professional) birth attendant in an enabling environment may be limited while the reasons for traditional midwives being the caregiver of choice for the majority of women living in areas such as Western Kenya remain unaddressed.

The perspectives of clients and unqualified allopathic practitioners on the management of delivery care in urban slums, Dhaka, Bangladesh – a mixed method study. T Wahed, AC Moran, M Iqbal. BMC Pregnancy and Childbirth, September 2010.
Background: BRAC is implementing a program to improve maternal and newborn health among the urban poor in the slums of Bangladesh (Mansohi), funded by the Bill & Melinda Gates Foundation. Formative research has demonstrated that unqualified allopathic practitioners (UAPs) are commonly assisting home-delivery. The objective of this study was to explore the role of unqualified allopathic practitioners during home delivery in urban slums of Dhaka. Methods: This cross-sectional study was conducted between September 2008 and June 2009 in Kamrangirchar slum in Dhaka, Bangladesh, using both qualitative and quantitative research methods. Through a door-to-door household survey, quantitative data were collected from 463 women with a home birth and/or trial of labor at home. We also conducted seven in-depth interviews with the UAPs to explore their practices. Results: About one-third (32%) of the 463 women interviewed sought delivery care from a UAP. We did not find an association between socio-demographic characteristics and care-seeking from a UAP, except for education of women. Compared to women with three or more pregnancies, the highest odds ratio was found in the primi-gravidity group [odds ratio (OR): 3.46; 95% confidence interval (CI): 1.65-7.25)], followed by women with two pregnancies (OR: 2.54; 95% CI: 1.36-4.77) to use a UAP. Of women who reported at least one delivery-related complication, 45.2% received care from the UAPs. Of 149 cases where the UAP was involved with delivery care, 133 (89.3%) received medicine to start or increase labor with only 6% (9 of 149) referred by a UAP to any health facility. The qualitative findings showed that UAPs provided a variety of medicines to manage excessive bleeding immediately after childbirth. Conclusion: There is demand among slum women for delivery-related care from UAPs during home births in Bangladesh. Some UAPs’ practices are contrary to current World Health Organization recommendations and could be harmful. Programs need to develop interventions to address these practices to improve perinatal care outcomes.

Violence during pregnancy and newborn outcomes: a cohort study in a disadvantaged population in Brazil. MA Antunes Nunes, S Camey, et al. The European Journal of Public Health, 2010.*
Background: Violence against pregnant women is an increasing public health concern. The purpose of this study is to estimate the prevalence of violence during pregnancy, to identify characteristics associated and to assess the impact of violence on newborn outcomes. Methods: Prospective cohort study of 652 pregnant women attending primary care clinics in Southern Brazil, from June 2006 to September 2007. Women with gestational age ranging from 16th and 36th were enrolled and their exposure to violence and mental disorder was assessed. After the birth they were contacted by telephone when information on obstetric and neonatal outcomes was obtained. Results: Any violence during current pregnancy was reported by 18.3% [95% confidence interval (CI) 15.3-21.4%] participants, 15.0% (95% CI 12.3-17.8%) psychological violence, 6% (95% CI 4.2-7.8%) physical violence and 3% (0-0.5%) sexual violence. These women were more often of low income, did not work or study and had inadequate prenatal care and pregnancy weight gain. There was a statistically significant crude association between exposure to physical and psychological violence [relative risk (RR) 3.21 (1.51-6.80)]. After adjustment for family income, number of prenatal visits, length of gestation and gestational weight gain, the effect size decreased, but remained statistically significant (RR 2.18; 95% CI 1.16-4.08%). Conclusion: In disadvantaged settings in Brazil, violence in pregnancy is frequent; it is associated with inadequate maternal weight gain during pregnancy and prenatal care, and increases risk of low birth-weight. Thus, violence in pregnancy imposes a challenge to effective prenatal care delivery with potential benefits to the mother and her baby.

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