A woman cannot die from a pregnancy she does not have

More than 99% of maternal deaths occur in low-resource settings; in parts of the developing world, as many as one in six women die of maternal causes. Currently, seven developing countries-Afghanistan, Angola, Malawi, Niger, Rwanda, Sierra Leone and Tanzania-have maternal mortality ratios of at least 1,400 maternal deaths per 100,000 live births.     

Younger women in Taiwan want smaller families,fewer sons; birth control use is found widespread

Studies in Taiwan indicate that the practice of birth control increased, the preferred family size declined, and the preference for sons decreased from 1965 to 1973. The proportion of young women who were married decreased as did the birth rate between 1965 and 1972. Illegal abortion continued to be practiced; almost 250,000 induced abortions were obtained in 1973. 70% of community leaders and 90% of gynecologists favor liberalization of the restrictive abortion law. Fertility declined most for women 30 years old and older in the 1960's; between 1970 and 1972 fertility declined for women under 30. The preferred number of children decreased with education and urbanization. Contraceptive use increased for all age and educational groups during these years. Contraception seems to be used more for spacing than for limitation of births.     

Obstetrics and perinatal outcome of pregnancies after the age of 45.

We set out to describe the maternal and perinatal outcome of pregnancies in women >/= 45 years old at the time of delivery. A retrospective review of hospital deliveries after 28 weeks of pregnancy was performed at the Princess Badeea Teaching Hospital (PBTH) in North Jordan for patients delivered between 1 April 1994 and 31 December 1997. During the study period, there were 114 women aged >/= 45 years at delivery at the PBTH. The incidence was 3.3 per 1000 births. The median maternal age was 45 years. The majority of women (81.6%) were 45-46 years old. Maternal ages were 45 (n =64), 46 (n =29), 47 (n =9), 48 (n =8), 49 (n =2) and 50 (n =2) years. Median gravidity was 10, median parity was seven. Forty-four (38.6%) patients had obstetric complications. The most frequent complication was diabetes mellitus (9.6%), followed by hypertension (4.4%). Caesarean section was performed in 32.5%. There were nine stillbirths and four early neonatal deaths, the perinatal mortality rate was 114/1000 births. We conclude that women >/= 45 years old at delivery have high perinatal mortality rate and we also noted a higher incidence of placental abruption, placenta praevia and caesarean delivery, compared with a younger group of women.     

Recurrence of preterm birth in singleton and twin pregnancies

OBJECTIVE: To assess recurrence of preterm birth and its impact on an obstetric population. METHODS: Women with consecutive births at our hospital beginning with their first pregnancy were identified (n = 15,945). The first pregnancy was categorized as delivered between 24 and 34 weeks' gestation or 35 weeks or beyond, singleton or twin, and spontaneous or induced. The risk of preterm delivery in these same women during subsequent pregnancies was then analyzed. RESULTS: Compared with women who delivered a singleton at or beyond 35 weeks' gestation in their first pregnancy, those who delivered a singleton before 35 weeks were at a significant increased risk for recurrence (odds ratio [OR] 5.6, 95% confidence interval [CI] 4.5, 7.0), whereas those who delivered twins were not (OR 1.9, 95% CI 0.46, 8.14). The OR for recurrent spontaneous preterm birth presenting with intact membranes was 7.9 (95% CI 5.6, 11.3) compared with 5.5 (95% CI 3.2, 9.4) with ruptured membranes. Of those women with a recurrent preterm birth, 49% delivered within 1 week of the gestational age of their first delivery and 70% delivered within 2 weeks. Among 15,863 nulliparous women with singleton births at their first delivery, a history of preterm birth in that pregnancy could predict only 10% of the preterm births that ultimately occurred in the entire obstetric population. CONCLUSION: In a population-based study at our hospital, women who initially delivered preterm and thus were identified to be at risk for recurrence ultimately accounted for only 10% of the prematurity problem in the cohort.     

Maternal factors and the probability of a planned home birth

OBJECTIVES: In the Netherlands, approximately one-third of births are planned home births, mostly supervised by a midwife. The relationship between maternal demographic factors and home births supervised by midwives was examined. DESIGN: Cross-sectional study. Setting Dutch national perinatal registries of the year 2000. POPULATION: All women starting their pregnancy care under the supervision of a midwife, because these women have the possibility of having a planned home birth. METHODS: The possible groups of birth were as follows: planned home birth or short stay hospital birth, both under the supervision of a midwife, or hospital birth under the supervision of an obstetrician after referral from the midwife during pregnancy or birth. The studied demographic factors were maternal age, parity, ethnicity and degree of urbanisation. Probabilities of having a planned home birth were calculated for women with different demographic profiles. MAIN OUTCOME MEASURE: Place of birth. RESULTS: In all age groups, the planned home birth percentage in primiparous women was lower than in multiparous women (23.5%vs 42.8%). A low home birth percentage was observed in women younger than 25 years. Dutch and non-Dutch women showed almost similar percentages of obstetrician-supervised hospital births but large differences in percentage of planned home births (36.5%vs 17.3%). Fewer home births were observed in large cities (30.5%) compared with small cities (35.7%) and rural areas (35.8%). CONCLUSIONS: This study demonstrates a clear relationship between maternal demographic factors and the place of birth and type of caregiver and therefore the probability of a planned home birth.     

Using scorecards to achieve facility improvements for maternal and newborn health

The Government of Sierra Leone launched the Free Health Care Initiative in 2010, which contributed to increased use of facility based maternity services. However, emergency obstetric and neonatal care (EmONC) facilities were few and were inadequately equipped to meet the increased demand. To ensure provision of EmONC in some priority facilities, the Ministry of Health and Sanitation undertook regular facility assessments. With the use of assessment tools and scorecards it is possible to make improvements to the services provided in the period after assessment. The exercise shows that evidence that is shared with providers in visually engaging formats can help decision-making for facility based improvements.     

Obstetric ethics: an essential dimension of planned home birth

The American College of Obstetricians and Gynecologists (the College) Committee Opinion, "Planned Home Birth," invokes two core concepts of obstetric ethics, the right of a woman to make a medically informed decision about delivery and the informed consent process. We set out a framework for obstetric ethics that empowers the autonomy of pregnant women by focusing on when, in beneficence-based clinical judgment, clinical management should be offered, should be recommended, and should be recommended against in the informed consent process. Using this ethical framework, we show that the College statement does not provide adequate guidance to obstetricians in fulfilling their ethical obligations in the informed consent process with pregnant women who express an interest in, or preference for planned home birth. Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it. Obstetricians should recommend hospital-based delivery and respond to refusal of these recommendations with respectful persuasion. As a matter of beneficence-based professional integrity, obstetricians should not participate in planned home birth. At the same time, obstetricians have a beneficence-based obligation to continue to provide prenatal and emergency obstetric care. The obstetric profession should continuously strive to make hospital births more humane and support home-birth-like environments in the hospital as well as continuously improve safety for both pregnant and fetal patients.     

Subsequent birth outcomes after an unexplained stillbirth: preliminary population-based retrospective cohort study

The objective of this study was to determine whether women who have experienced an unexplained stillbirth have a higher risk of adverse perinatal outcomes in subsequent births. We compared 316 subsequent births to women with a previous unexplained stillbirth, with 3160 births to women with no previous history of stillbirth, matched by year of birth, in the period 1987-1997, from the South Australian perinatal database, using logistic regression analysis. There was no increase in the rate of stillbirth and no statistically significant increase in the rate of perinatal death (OR 1.62 [95%CI 0.63-4.20]) or neonatal death, although larger studies are needed to confirm this. However, after adjusting for age, parity, and hospital category of birth, women who had a previous stillbirth had increased incidences in subsequent births of abnormal glucose tolerance or gestational diabetes (a fourfold increase); induction of labour and elective Caesarean section; fetal distress and postpartum haemorrhage; and forceps and emergency Caesarean delivery and preterm birth, which were independent of induction of labour. Gestational age at birth and birthweight were also significantly reduced, suggesting a need for close monitoring of their future pregnancies.     

Term breech birth in New South Wales, 1990-1997

Data on 636,708 women delivering a singleton infant of gestational age > or =37 weeks in NSW from 1 January 1990 to 31 December 1997 were used to examine trends in breech births at term and the mode of delivery. From 1990 to 1997, although the crude rate of breech births at term remained stable at 3.4%, the adjusted odds ratio for breech birth compared with cephalic birth decreased over time. Among live breech births, the crude rate of vaginal breech birth declined from 29.4% to 19.7%, with an attendant increase in elective Caesarean sections from 49.1% to 58.4%. Most of this increase was at 38 and 39 weeks gestation. There was no change in the perinatal mortality rate among breech births during the study period. Despite increasing maternal age, the adjusted odds of a breech birth at term decreased over time. This could be due to offsetting factors, such as increased use of external cephalic version. If the decrease in vaginal breech birth continues, it may lead to the skills for this procedure being lost.     

Estimated effect of 17 alpha-hydroxyprogesterone caproate on preterm birth in the United States

OBJECTIVE: A multicenter, randomized placebo-controlled trial among women with singleton pregnancies and a history of spontaneous preterm birth found that weekly injections of 17 alpha-hydroxyprogesterone caproate (17P), initiated between 16 and 20 weeks of gestation, reduced preterm birth by 33%. The current study estimated both preterm birth recurrence and the potential reduction in the national preterm birth rate. METHODS: Using 2002 national birth certificate data, augmented by vital statistics from 2 states, we estimated the number of singleton births delivered to women eligible for 17P through both a history of spontaneous preterm birth and prenatal care onset within the first 4 months of pregnancy. The number and rate of recurrent spontaneous preterm births were estimated. To predict effect, the reported 33% reduction in spontaneous preterm birth attributed to 17P therapy was applied to these estimates. RESULTS: In 2002, approximately 30,000 recurrent preterm births occurred to women eligible for 17P, having had a recurrent preterm birth rate of 22.5%. If 17P therapy were delivered to these women, nearly 10,000 spontaneous preterm births would have been prevented, thereby reducing the overall United States preterm birth rate by approximately 2%, from 12.1% to 11.8% (P < .001), with higher reductions in targeted groups of eligible pregnant women. CONCLUSION: Use of 17P could reduce preterm birth among eligible women, but would likely have a modest effect on the national preterm birth rate. Additional research is urgently needed to identify other populations who might benefit from 17P, evaluate new methods for early detection of women at risk, and develop additional prevention strategies. LEVEL OF EVIDENCE: III.     

Childbearing in adolescents aged 12-15 years in low resource countries: a neglected issue. New estimates from demographic and household surveys in 42 countries

There is strong evidence that the health risks associated with adolescent pregnancy are concentrated among the youngest girls (e.g. those under 16 years). Fertility rates in this age group have not previously been comprehensively estimated and published. By drawing data from 42 large, nationally representative household surveys in low resource countries carried out since 2003 this article presents estimates of age-specific birth rates for girls aged 12-15, and the percentage of girls who give birth at age 15 or younger. From these we estimate that approximately 2.5 million births occur to girls aged under 16 in low resource countries each year. The highest rates are found in Sub-Saharan Africa, where in Chad, Guinea, Mali, Mozambique, Niger and Sierra Leone more than 10% of girls become mothers before they are 16. Strategies to reduce these high levels are vital if we are to alleviate poor reproductive health.     

Maternal and perinatal outcome of pregnancies after the age of 45

OBJECTIVE: To describe the maternal and perinatal outcome of pregnancies in women aged 45 years or more at the time of delivery and to compare them with pregnancies in women aged between 20 and 29 years. METHODS: A retrospective review of hospital deliveries after 28 weeks gestation was performed at the Princess Badeea Teaching Hospital in North Jordan for patients delivered between 1st April 1994 and 31st December 1997. We compared the maternal and perinatal outcome of pregnancies in women aged of 45 years or more (study group, n = 114) with women aged between 20-29 years (control group, n = 121) delivered at the same hospital during the same period. RESULTS: The incidence of pregnant women aged 45 years or more was 3.3 per 1,000 births. The median maternal age was 45 years. The majority of women (81.6%) were 45 to 46 years old. Gravidity and parity was significantly higher in the study group (p < 0.0001), also antenatal and medical complications as pre-eclampsia and diabetes mellitus were higher in the study group. Caesarean section rate, incidences of placental abruption and placenta previa were more common in older patients compared with young patients (32.4 vs 10.7%, 6.1 vs 0.8% and 4.4 vs 1.6%, respectively). There were no differences in the incidences of neonatal deaths, lethal malformations and fetal weight between the 2 groups. CONCLUSION: Women aged 45 years or more at delivery may expect a good pregnancy outcome but should expect a higher incidences of placental abruption, placenta previa, preeclampsia and caesarean delivery.     

Impact of traditional birth attendant training in Mozambique: a controlled study

This study was designed to assess the utility and impact on perinatal mortality of a model traditional birth attendant (TBA) training program in rural Mozambique by comparing birth attendance and outcomes in similar communities with and without trained TBAs. Birth attendants and pregnancy outcomes were compared in 1) communities with good access to trained TBAs, 2) randomly selected, comparable communities with no access to trained TBAs, and 3) communities with good access to functioning maternities. Information was collected by interviews with women in randomly selected households. A total of 4,169 women were interviewed who reported on 3,616 completed pregnancies, which resulted in a birth or fetal death. Among women with good access to trained TBAs, 33% reported giving birth attended by a trained TBA, 43% reported giving birth at a health facility, and 24% reported giving birth attended by an untrained person. Among women without access to trained TBAs, 58% reported giving birth at health facilities, and 42% reported attendance by untrained persons. Among women with access to functioning maternity centers, 77% reported giving birth at a health facility and 22% said their birth was attended by an untrained person. There was no significant difference in perinatal or infant mortality among the groups. This study demonstrated a preference for health facility deliveries among rural Mozambican women with good access to trained TBAs. It also failed to demonstrate a reduction in perinatal or infant mortality associated with TBA training. Women said they preferred to deliver in health facilities because conditions were considered better and interventions could be performed if needed. The preference for health facility birth over home birth with a TBA may have been related to difficulties with TBA neighbors and their families or fear of potential witchcraft. Efforts to promote TBA training should be balanced with support for birthing services based in health facilities.     

The Yolo County Midwifery Service. A descriptive study of 496 singleton birth outcomes, 1990.

The Yolo County Midwifery Service was begun in January 1989 to serve pregnant low-income women who were denied care by local obstetricians. In 1990, 58% of women served were Latina and 33% were Anglo-white. Their mean age was 24.5 +/- 5.5 years, and their mean level of education was 9.9 +/- 3.5 years. Thirty-seven percent were nulliparous. All deliveries were at the only hospital in the county with a maternity service. To evaluate the effectiveness of nurse-midwifery care in this sample, a prospective study of the service's 496 singleton birth outcomes during 1990 was undertaken. Although the cesarean rate in 1990 for the obstetricians not associated with the midwifery service at this hospital was 20.6%, the midwifery clients experienced a primary cesarean birth rate of 3.7% and a total rate of 6.7%. Instrument-assisted deliveries took place for 1.0% of births. The success rate for women attempting vaginal birth after cesarean was 87.2%. Delivery over an intact perineum occurred for 51.8%. Preterm birth was experienced by only 1.0% of the women. A newborn birth weight of < 2,500 g occurred in 2.4% of births. Occult cord prolapse preceded a single neonatal death, resulting in a perinatal and neonatal death rate of two per 1,000. These data add to the growing body of information about nurse-midwifery in which that care is found to be a safe, well-accepted, and cost-effective adjunct to existing obstetric care services.     

Induced abortion and risk of small-for-gestational-age birth

Objective  To investigate the possibility of an association between previous induced abortion and subsequent birth of a small-for-gestational-age (SGA) infant.
Design  Case–control study.
Setting  General and university hospitals.
Methods  Cases were 555 women who delivered SGA babies. Controls were 1966 women who gave birth at term (>37 weeks of gestation) to healthy infants of normal weight on randomly selected days at the hospital where cases had been identified. All women in the case and control categories were interviewed on the obstetric wards by one of a team of six interviewers. During the interviews, information was obtained regarding general socio-demographic factors, personal characteristics and habits, gynaecological and obstetric history, general anamnesis, family history of obstetric and gynaecological diseases, and the age of the father of the child. Further information on current pregnancy and delivery was also collected. We used conditional multiple logistic regression (with age as the matching variable), with maximum likelihood fitting, to obtain odds ratios and their corresponding 95% CIs. Included in the regression equations were terms for education, plus terms significantly associated in this data set with the risk of SGA birth (smoking in pregnancy, history of SGA, gestational hypertension and parity).
Population  Women admitted to a general and a university hospital.
Results  No significant increase in the risk of SGA birth was observed in women with a previous induced abortion [odds ratio (OR) 1.0; 95% CI 0.6–1.7]. The OR for SGA birth was 1.2 (95% CI 0.7–2.1) for preterm and 1.0 (95% CI 0.7–1.4) for term SGA births.
Conclusion  This study found no association between risk of SGA birth and induced abortion.     

Vaginal birth after cesarean section: a reappraisal of risk

A three-year retrospective study was performed to assess morbidity associated with an attempted vaginal birth after cesarean section at a tertiary level military obstetric hospital. Examination of delivery records revealed a 61.16% success rate for attempted vaginal births after cesarean sections. Mean birth weights differed significantly between successful and unsuccessful vaginal births after cesarean sections. Infants with birth weights greater than 3720 gm were less likely to be vaginally delivered. Those gravidas with a successful vaginal birth after cesarean section had a significantly higher rate of perineal lacerations, as compared with other vaginal births during the study period. The scar separation rate of 1.79% was significantly higher than the 0.50% rate reported elsewhere. One patient who attempted a vaginal birth after cesarean section required a cesarean hysterectomy after scar separation occurred during labor. There were two perinatal deaths, both of which occurred at greater than 40 weeks' gestation, for a perinatal mortality rate of 8.93/1000 births. Women who consider vaginal birth after cesarean section should be counseled with regard to the increased risk of perineal trauma. Estimates of fetal weight at term should be a part of the decision-making process before vaginal birth after cesarean section is attempted.     

The cost-effectiveness of home birth

As health care costs increase and a growing number of women are without insurance, the one health service that every family needs deserves further attention. Even for the 40% of births covered by Medicaid, safe birthing alternatives that permit a reduction in the $150 billion Medicaid burden would allow the United States to devote more resources to other urgent priorities. Informed birthing decisions cannot be made without information on costs, success rates, and any necessary tradeoffs between the two. This article provides the relevant information for hospital, home, and birth center births. The average uncomplicated vaginal birth costs 68% less in a home than in a hospital, and births initiated in the home offer a lower combined rate of intrapartum and neonatal mortality and a lower incidence of cesarean delivery.     

Utilisation of skilled birth attendance in Northern Nigeria: A cross-sectional survey

Objective

to determine the level and determinants for utilisation of Skilled Birth Attendance (SBA).

Methods

a population-based survey using a structured questionnaire was conducted in Goya and Tundunya political wards of Katsina state from May to June 2012. Four hundred women aged 15–49 years who had delivered a baby within two years prior to the study were asked about birth attendance during antenatal care (ANC), childbirth and postnatal period of their most recent birth. Logistic regression analysis was performed to obtain independent predictors of skilled birth attendance (SBA).

Findings

of the 400 women recruited for the study, 145 (36.3%) received antenatal care, 52 (13%) had their births assisted by skilled personnel and 88 (22%) received postnatal care from skilled birth attendants. Of the 52 women who had their births attended by skilled birth attendants only 29 (56%) had their births in a health facility. Maternal education, husband's occupation, presence of complication and previous place of childbirth were found to be statistically significant predictors for SBA utilisation. Barriers to SBA utilisation identified included lack of health care provider, lack of equipment and supplies and poverty. Enablers mentioned included availability of staff, husband's approval and affordable service.

Conclusion

women are more likely to utilise SBA with the availability of skilled personnel, strengthening of the health system and intervention to remove user fees for maternal health services. Joint effort should be made by government and community leaders to promote girl's education and to encourage men's involvement in maternal health services.