Reducing intrapartum-related neonatal deaths in low- and middle-income countries-what works?

Each year, 814,000 neonatal deaths and 1.02 million stillbirths result from intrapartum-related causes, such as intrauterine hypoxia. Almost all of these deaths are in low- and middle-income countries, where women frequently lack access to quality perinatal care and may delay care-seeking. Approximately 60 million annual births occur outside of health facilities, and most of these childbirths are without a skilled birth attendant. Conditions that increase the risk of intrauterine hypoxia--such as pre-eclampsia/eclampsia, obstructed labor, and low birth weight--are often more prevalent in low resource settings. Intrapartum-related neonatal deaths can be averted by a range of interventions that prevent intrapartum complications (eg, prevention and management of pre-eclampsia), detect and manage intrapartum problems (eg, monitoring progress of labor with access to emergency obstetrical care), and identify and assist the nonbreathing newborn (eg, stimulation and bag-mask ventilation). Simple, affordable, and effective approaches are available for low-resource settings, including community-based strategies to increase skilled birth attendance, partograph use by frontline health workers linked to emergency obstetrical care services, task shifting to increase access to Cesarean delivery, and simplified neonatal resuscitation training (Helping Babies Breathe(SM)). Coverage of effective interventions is low, however, and many opportunities are missed to provide quality care within existing health systems. In sub-Saharan Africa, recent health services assessments found only 15% of hospitals equipped to provide basic neonatal resuscitation. In the short term, intrapartum-related neonatal deaths can be substantially reduced by improving the quality of services for all childbirths that occur in health facilities, identifying and addressing the missed opportunities to provide effective interventions to those who seek facility-based care. For example, providing neonatal resuscitation for 90% of deliveries currently taking place in health facilities would save more than 93,000 newborn lives each year. Longer-term strategies must address the gaps in coverage of institutional delivery, skilled birth attendance, and quality by strengthening health systems, increasing demand for care, and improving community-based services. Both short- and long-term strategies to reduce intrapartum-related mortality should focus on reducing inequities in coverage and quality of obstetrical and perinatal care.     

ENC training reduces perinatal mortality in Karnataka,India

Objective: To evaluate the effect of World Health Organization Essential Newborn Care course and the American Academy of Pediatrics Neonatal Resuscitation Program training on perinatal mortality in rural India. Methods: This study was part of a multi-country prospective, community-based cluster randomized controlled trial. Birth, 7-day and 28-day neonatal outcomes for all women with pregnancies greater than 28 weeks in the 26 study communities in Karnataka, India were included. Mortality rates pre- and post-Essential Newborn Care training were collected prospectively and then communities randomized to either receive neonatal resuscitation or refresher newborn care training in the control clusters. Results: Consent was obtained on 99% of the 25,096 births. Perinatal mortality for infants ≥500 g decreased from 52 to 36/1000 after newborn care training (RR 0.7; 95% CI 0.5, 0.9); stillbirth decreased from 23 to 14/1000 (RR 0.62; 95% CI 0.46, 0.83) and early neonatal mortality decreased from 29 to 22/1000 (RR 0.74; 95% CI 0.53, 1.03). Mortality was not reduced further with resuscitation training. Conclusions: Using a pre–post design, World Health Organization Essential Newborn Care community birth attendant training resulted in a significant reduction in perinatal mortality. In low-resource settings, the newborn care training package appears to be an effective intervention to decrease perinatal mortality.     

Implementing a facility-based maternal and perinatal health care surveillance system in Afghanistan

Afghanistan has one of the highest maternal and perinatal mortality rates in the world. Lack of a health information system presented obstacles to efforts to improve the quality of care and reduce mortality. To rapidly overcome this deficit in a large women's hospital, staff implemented a facility-based maternal and perinatal surveillance system known as "BABIES," which is specially designed for intervention and evaluation in low-resource settings. During a 12-month period, 15,509 deliveries resulted in 28 maternal deaths and a perinatal mortality rate of 56 per 1000 births. When stratified by birth weight and perinatal period of death, fetuses weighing at least 2500 g who died during the antepartum period contributed the most cases of perinatal death. This finding suggests that the greatest reduction in perinatal mortality would be realized by increasing access to high-quality antepartum care. Among fetuses weighing at least 2500 g, 93 deaths occurred during the intrapartum period. These deaths will continue to be monitored to ensure that the chosen interventions are improving intrapartum care for mothers and newborns. Because of its simplicity, flexibility, and ability to identify interventions, BABIES is a valuable tool that enables clinicians and program managers to prioritize resources.     

Practical simulation training for maternity care--where we are and where next

Improving maternal and perinatal care is a global priority. Practical simulation training for maternity care might prevent many of these deaths. There have been numerous evaluation studies published on the effectiveness of simulation training for obstetric emergencies, with increasing evidence that it is associated with improvement in clinical outcomes. Evidence has begun to move from subjective assessment of participants' experiences towards objective assessment of clinical outcomes. However, the results are not entirely consistent and, at present, all of the evidence associating training with improvements in clinical outcomes relates to neonatal outcomes. This review summarises recent progress in the evaluation of the effectiveness of simulation training for maternity care in both high- and low-resource settings, and presents a vision for ensuring that practical simulation training for maternity care can become an effective tool to reduce global maternal and perinatal morbidity and mortality.     

Outcome of very-low-birth-weight infants: does antepartum versus neonatal referral have a better impact on mortality, morbidity, or long-term outcome?

To evaluate the effect of aggressive intrapartum and early neonatal resuscitation on perinatal mortality, neonatal morbidity, and long-term outcome, we evaluated two groups of low-birth-weight infants who received different intrapartum and early neonatal care. One group of infants was delivered at a university-based regional perinatal center offering both high-risk obstetric and tertiary neonatal care. The second population consisted of infants from five community hospitals with level I nurseries. These two groups were selected because they differed in the ability to provide intrapartum and early neonatal care and because a total base population could be evaluated. During the 4-year study period, 174 infants with birth weights of 500 to 1499 gm were delivered at the university center and 297 infants were delivered at the community hospitals. At the university center, there was a significant reduction in fetal deaths, a delay in the time of neonatal deaths, and a reduction in hyaline membrane disease. Neonatal mortality rates at the university center were not reduced, and the incidence of sequelae was not affected. These data suggest that for the smallest infant, intrapartum and immediate neonatal care at a tertiary center may decrease fetal mortality and neonatal morbidity rates. Neonatal mortality and long-term outcome, however, may be less affected.     

Triplet pregnancy: changes in morbidity and mortality

The outcome of 13 sets of triplet infants delivered between January 1, 1981, and December 31, 1988, is analyzed with specific regard to immediate neonatal morbidity. Thirty-nine viable infants were born with no perinatal deaths. Overall, 80% of triplet infants incurred some morbidity, including hyperbilirubinemia (51.3%), hypoglycemia (30.8%), respiratory distress syndrome (28.2%), respiratory compromise (23.1%), anemia (17.9%), patent ductus arteriosus (15.4%), and intraventricular hemorrhage (10.3%). All morbidities occurred in infants who averaged less than 2,000 g and 35 weeks' gestation at birth. As a background to understanding these observations, a review of reports of triplet morbidity and mortality in the United States and Europe is presented. Over the past 80 years, a continual decline in triplet perinatal mortality has occurred despite no change in the average gestational age at delivery over the past 40 years. The triplet perinatal mortality rate is now less than 10%, and prematurity is no longer as influential on perinatal mortality as it is on morbidity. Improvement in neonatal resuscitation and care and delivery by cesarean section are felt to be responsible for lower mortality rates. We believe that the optimum level of care for triplet gestations includes antenatal and neonatal care at tertiary perinatal centers and, except for special circumstances, delivery by cesarean section.     

Organization of neonatal care services and its importance

Universally 4 million newborns die and another 4 million are stillborn every year. 98% of these neonatal deaths take place in the developing countries. Looking at the state of the world's newborns one can see that neonatal mortality rate is about 4-5 per 1000 in the developed countries and nearly 10 fold this in the developing world. Causes that underlie these newborn deaths differ according to a country's development rank. According to the WHO estimates for the year 2001, newborns die due to infections (32%), birth asphyxia and trauma (29%), prematurity (24%) and congenital anomalies (10%), mostly in the developing countries. When organizing neonatal care services in a country or a region, priorities should be decided by looking at neonatal and perinatal mortality rates and causes of neonatal and perinatal deaths. Causes of neonatal and perinatal deaths in the developing countries have been documented and reflect some common underlying problems in the health systems. Starting points in the organization of neonatal health care services seem to include: improving women's health and social status, family planning practices, antenatal care and safe delivery conditions. Attention should also be paid to neonatal resuscitation, essential newborn care and sick newborn care practices. Communities and health professionals should be advocates of newborn health in order to seek and deliver newborn health care. Existing health systems should be re-organized to host regionalized perinatal care.     

Evidence from community level inputs to improve quality of care for maternal and newborn health: interventions and findings

Annually around 40 million mothers give birth at home without any trained health worker. Consequently, most of the maternal and neonatal mortalities occur at the community level due to lack of good quality care during labour and birth. Interventions delivered at the community level have not only been advocated to improve access and coverage of essential interventions but also to reduce the existing disparities and reaching the hard to reach. In this paper, we have reviewed the effectiveness of care delivered through community level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined community level interventions and report findings from 43 systematic reviews.Findings suggest that home visitation significantly improved antenatal care, tetanus immunization coverage, referral and early initiation of breast feeding with reductions in antenatal hospital admission, cesarean-section rates birth, maternal morbidity, neonatal mortality and perinatal mortality. Task shifting to midwives and community health workers has shown to significantly improve immunization uptake and breast feeding initiation with reductions in antenatal hospitalization, episiotomy, instrumental delivery and hospital stay. Training of traditional birth attendants as a part of community based intervention package has significant impact on referrals, early breast feeding, maternal morbidity, neonatal mortality, and perinatal mortality. Formation of community based support groups decreased maternal morbidity, neonatal mortality, perinatal mortality with improved referrals and early breast feeding rates. At community level, home visitation, community mobilization and training of community health workers and traditional birth attendants have the maximum potential to improve a range of maternal and newborn health outcomes. There is lack of data to establish effectiveness of outreach services, mass media campaigns and community education as standalone interventions. Future efforts should be concerted on increasing the availability and training of the community based skilled health workers especially in resource limited settings where the highest burden exists with limited resources to mobilize.     

Neonatal Outcomes in the Birth Center Setting: A Systematic Review

Introduction

This systematic review investigates the effect of the birth center setting on neonatal mortality in economically developed countries to aid women and clinicians in decision making.

Methods

We searched the Google Scholar, CINAHL, and PubMed databases using key terms birth/birthing center or out of hospital with perinatal/neonatal outcomes. Ancestry searches identified additional studies, and an alert was set for new publications. We included primary source studies in English, published after 1980, conducted in a developed country, and researching planned birth in centers with guidelines similar to American Association of Birth Centers standards. After initial review, we conducted a preliminary analysis, assessing which measures of neonatal health, morbidity, and mortality were included across studies.

Results

Neonatal mortality was selected as the sole summary measure as other measures were sporadically reported or inconsistently defined. Seventeen studies were included, representing at least 84,500 women admitted to a birth center in labor. There were substantial differences of study design, sampling techniques, and definitions of neonatal outcomes across studies, limiting conclusive statements of the effect of intrapartum care in a birth center. No reviewed study found a statistically increased rate of neonatal mortality in birth centers compared to low‐risk women giving birth in hospitals, nor did data suggest a trend toward higher neonatal mortality in birth centers. As in all birth settings, nulliparous women, women aged greater than 35 years, and women with pregnancies of more than 42 weeks’ gestation may have an increased risk of neonatal mortality.

Discussion

There are substantial flaws in the literature concerning the effect of birth center care on neonatal outcomes. More research is needed on subgroups at risk of poor outcomes in the birth center environment. To expedite research, consistent use of national and international definitions of perinatal and neonatal mortality within data registries and greater detail on adverse outcomes would be beneficial.     

关于超早产儿救治的出生胎龄低限和分娩场所的建议

21世纪以来,随着我国围产医学和新生儿救治技术的飞速发展,超早产儿救治存活率和预后均有很大改善。但许多超早产儿未能在设置有省级危重孕产妇和新生儿救治中心的具备救治条件的医院出生,进入新生儿重症监护病房治疗的比例较低。为提升我国超早产儿救治的水平,本文就超早产儿救治的出生胎龄低限和分娩场所进行了讨论,并提出了相应建议。     

Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand

Background

Although a number of antenatal and intrapartum interventions have shown some evidence of impact on stillbirth incidence, much confusion surrounds ideal strategies for delivering these interventions within health systems, particularly in low-/middle-income countries where 98% of the world's stillbirths occur. Improving the uptake of quality antenatal and intrapartum care is critical for evidence-based interventions to generate an impact at the population level. This concluding paper of a series of papers reviewing the evidence for stillbirth interventions examines the evidence for community and health systems approaches to improve uptake and quality of antenatal and intrapartum care, and synthesises programme and policy recommendations for how best to deliver evidence-based interventions at community and facility levels, across the continuum of care, to reduce stillbirths.

Methods

We systematically searched PubMed and the Cochrane Library for abstracts pertaining to community-based and health-systems strategies to increase uptake and quality of antenatal and intrapartum care services. We also sought abstracts which reported impact on stillbirths or perinatal mortality. Searches used multiple combinations of broad and specific search terms and prioritised rigorous randomised controlled trials and meta-analyses where available. Wherever eligible randomised controlled trials were identified after a Cochrane review had been published, we conducted new meta-analyses based on the original Cochrane criteria.

Results

In low-resource settings, cost, distance and the time needed to access care are major barriers for effective uptake of antenatal and particularly intrapartum services. A number of innovative strategies to surmount cost, distance, and time barriers to accessing care were identified and evaluated; of these, community financial incentives, loan/insurance schemes, and maternity waiting homes seem promising, but few studies have reported or evaluated the impact of the wide-scale implementation of these strategies on stillbirth rates. Strategies to improve quality of care by upgrading the skills of community cadres have shown demonstrable impact on perinatal mortality, particularly in conjunction with health systems strengthening and facilitation of referrals. Neonatal resuscitation training for physicians and other health workers shows potential to prevent many neonatal deaths currently misclassified as stillbirths. Perinatal audit systems, which aim to improve quality of care by identifying deficiencies in care, are a quality improvement measure that shows some evidence of benefit for changes in clinical practice that prevent stillbirths, and are strongly recommended wherever practical, whether as hospital case review or as confidential enquiry at district or national level.

Conclusion

Delivering interventions to reduce the global burden of stillbirths requires action at all levels of the health system. Packages of interventions should be tailored to local conditions, including local levels and causes of stillbirth, accessibility of care and health system resources and provider skill. Antenatal care can potentially serve as a platform to deliver interventions to improve maternal nutrition, promote behaviour change to reduce harmful exposures and risk of infections, screen for and treat risk factors, and encourage skilled attendance at birth. Following the example of high-income countries, improving intrapartum monitoring for fetal distress and access to Caesarean section in low-/middle-income countries appears to be key to reducing intrapartum stillbirth. In remote or low-resource settings, families and communities can be galvanised to demand and seek quality care through financial incentives and health promotion efforts of local cadres of health workers, though these interventions often require simultaneous health systems strengthening. Perinatal audit can aid in the development of better standards of care, improving quality in health systems. Effective strategies to prevent stillbirth are known; gaps remain in the data, the evidence and perhaps most significantly, the political will to implement these strategies at scale.

     

Assessing skilled birth attendants and emergency obstetric care in rural Tanzania: the inadequacy of using global standards and indicators to measure local realities

Current efforts to reduce maternal mortality and morbidity in low-resource settings often depend on global standards and indicators to assess obstetric care, particularly skilled birth attendants and emergency obstetric care. This paper describes challenges in using these standards to assess obstetric services in the Kilombero Valley of Tanzania. A health facility survey and extensive participant observation showed existing services to be complicated and fluid, involving a wide array of skills, resources, and improvisations. Attempts to measure these services against established standards and indicators were not successful. Some aspects of care were over-valued while others were under-valued, with significant neglect of context and quality. This paper discusses the implications of these findings for ongoing maternal health care efforts in unique and complex settings, questioning the current reliance on generic (and often obscure) archetypes of obstetric care in policy and programming. It suggests that current indicators may be insufficient to assess services in low-resource settings, but not that these settings should settle for lower standards of care. In addition to global benchmarks, assessment approaches that emphasize quality of care and recognize available resources might better account for local realities, leading to more effective, more sustainable service delivery.     

Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births

Objective  To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care.
Design  A nationwide cohort study.
Setting  The entire Netherlands.
Population  A total of 529 688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321 307 (60.7%) intended to give birth at home, 163 261 (30.8%) planned to give birth in hospital and for 45 120 (8.5%), the intended place of birth was unknown.
Methods  Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics.
Main outcome measures  Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit.
Results  No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16).
Conclusions  This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.     

OUTCOMES OF 11,788 PLANNED HOME BIRTHS ATTENDED BY CERTIFIED NURSE-MIDWIVES

This study describes the outcomes of 11,788 planned home births attended by certified nurse-midwives (CNMs) from 1987 to 1991. A retrospective survey was used to obtain information about the outcomes of intended home birth, including hospital transfers, as well as practice protocols, risk screening, and emergency preparedness. Ninety nurse-midwifery home birth practices provided data for this report (66.2% of identified nurse-midwifery home birth practices). It is estimated that 60–70% of all CNM-attended home births reported in national statistics data during this period were represented in this survey. The overall perinatal mortality was 4.2 per 1,000, including known third-trimester fetal demises. There were no maternal deaths. The intrapartum and neonatal mortality for those intending home birth at the onset of labor was 2 per 1,000; the overall neonatal mortality rate for this group was 1.3 per 1,000. When deaths associated with congenital anomalies were excluded, the intrapartum and neonatal mortality rate was 0.9 per 1,000; the neonatal mortality was 0.2 per 1,000. The overall transfer rate, including antepartum referrals, was 15.9%. The intrapartum transfer rate for those intending home birth at the onset of labor was 8%. Most responding nurse-midwives used standard risk-assessment criteria, only delivered low-risk women at home, and were prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies. This study supports previous research indicating that planned home birth with qualified care providers can be a safe alternative for healthy lower risk women.     

Outcomes of 11,788 planned home births attended by certified nurse-midwives A retrospective descriptive study

This study describes the outcomes of 11,788 planned home births attended by certified nurse-midwives (CNMs) from 1987 to 1991: A retrospective survey was used to obtain information about the outcomes of intended home birth, including hospital transfers, as well as practice protocols, risk screening, and emergency preparedness. Ninety nurse-midwifery home birth practices provided data for this report (66.2% of identified nurse-midwifery) home birth practices). It is estimated that 60–70% of all CNM-attended home births reported in national statistics data during this period were represented in this survey. The overall perinatal mortality was 4.2 per 1,000, including known third-trimester fetal demises. There were no maternal deaths. The intrapartum and neonatal mortality for those intending home birth at the onset of labor was 2 per 1,000; the overall neonatal mortality rate for this group was 1.3 per 1,000. When deaths associated with congenital anomalies were excluded, the intrapartum and neonatal mortality rate was 0.9 per 1,000; the neonatal mortality was 0.2 per 1,000. The overall transfer rate, including antepartum referrals, was 15.9%. The intrapartium transfer rate for those intending home birth at the onset of labor was 8%. Most responding nurse-midwives used standard risk-assessment criteria, only delivered low-risk women at home, and were prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies. This study supports previous research indicating that planned home birth with qualified care providers can be a safe alternative for healthy lower risk women.     

Helping Babies Breathe Around the World

Helping Babies Breathe (HBB) is an educational curriculum using the train‐the‐trainer model to teach neonatal resuscitation in resource limited areas. The purpose of this evidence‐based program is to reduce global neonatal mortality by educating birth attendants to provide basic neonatal resuscitation. This program directly addresses the Millennium Developmental Goal #4 of reducing child mortality.     

The impact of publicly funded perinatal care programs on neonatal outcome, Georgia, 1976-1978

The State of Georgia administers three publicly funded perinatal care programs for medically high risk and/or low-income women: the High Risk Pregnancy Program, the Medicaid Program, and the Maternal and Infant Care Projects. To assess the impact of these programs on infant health, we compared the birth weight distribution and neonatal mortality rates of infants born to women in each program with those of infants of a nonfunded group of women with less than 12 years' education. Infants of women in publicly funded groups were more likely to weigh less than or equal to 2,500 gm at birth than those of women in the nonfunded group. Neonatal mortality rates for publicly funded groups were similar to those of the nonfunded group. The neonatal mortality rates for infants of birth weight less than or equal to 2,500 gm of publicly-funded women were significantly lower than those of the nonfunded women. There were no significant differences between groups for neonatal mortality rates for infants of birth weight greater than 2,500 gm. These findings suggest that publicly funded perinatal care programs may improve neonatal survival of infants of birth weight less than or equal to 2,500 gm of low-income mothers.     

Temperature control of premature infants in the delivery room

The body temperature of preterm babies can drop precipitously after delivery, and this hypothermia is associated with an increase in mortality and morbidity. Reports of hypothermia in babies of all birth weights, on admission to neonatal units, have come from all over the world; most also report increased mortality in association with hypothermia. Recent reports that showed that hypothermia on admission to neonatal units is an independent risk factor for mortality in preterm babies have refocused attention on the need for meticulous thermal care immediately after birth and during resuscitation. Their data lend weight to the view that conventional approaches to thermal care of the very preterm and low birth weight baby are outmoded.     

Impact of infants born at the threshold of viability on the neonatal mortality rate in Colorado.

OBJECTIVE: To determine the contribution of infants born at the threshold of viability (< 750 gm) on neonatal mortality in Colorado. STUDY DESIGN: For the period of January 1991 to December 1996, all Colorado live births who expired were evaluated for gestational age, birth weight, gender, hospital level of care, age at time of death, delivery room resuscitation, mechanical ventilation, medical and surgical complications, and serious malformations. RESULTS: Although infants weighing < 750 gm represent only 0.31% of all live births, they account for 46.3% of deaths. While those infants weighing < 500 gm and with a gestation of < 24 weeks almost always died (94.7%), the majority born in the 500- to 745-gm category (55.8%) survived. The vast majority (88.5%) of deaths occurred on the first day of life. A total of 38.4% of births in which the infant weighed < 750 gm occurred outside bona fide regional perinatal centers. CONCLUSION: Future attempts to reduce the Colorado neonatal mortality rate would best focus on the 500- to 750-gm weight group through the re-regionalization of high-risk perinatal care.