Commentary: reducing the world's stillbirths

One of the major success stories of modern obstetrics in high-income countries in the last 5 decades is the reduction of stillbirths from rates as high as 50 per 1000 births to about 5 per 1000 births today. Fetal mortality associated with obstructed labour, asphyxia, hypertension, diabetes, Rh disease, placental abruption, post-term pregnancies and infections such as syphilis all have declined. Much of this success has occurred in term births in the intrapartum period so that most stillbirths in high-income countries now occur in the antepartum period and are pre-term. Current stillbirth rates in many low- and middle-income countries, and especially in those areas within the countries with poorly functioning health systems, approximate those seen in high-income countries 50 years ago. A major difference between the stillbirths occurring in high-income countries and those occurring elsewhere is the preponderance of late pre-term, term and intrapartum stillbirths in low-resource countries. Those stillbirths should be relatively easy to prevent by known risk assessment methods and prompt delivery, often by Cesarean section. This commentary addresses an extensive six-paper review of stillbirths with an emphasis on low- and middle-income countries. Among the conclusions are that while a number of interventions have been shown to be effective in reducing stillbirths, unless there is a functioning health system in which these interventions can be implemented, the potential for a sustainable and substantial reduction in stillbirth rates will not be reached.     

Neonatal death in low- to middle-income countries: a global network study

Objective To determine population-based neonatal mortality rates in low- and middle-income countries and to examine gestational age, birth weight, and timing of death to assess the potentially preventable neonatal deaths.Methods A prospective observational study was conducted in communities in five low-income countries (Kenya, Zambia, Guatemala, India, and Pakistan) and one middle-income country (Argentina). Over a 2-year period, all pregnant women in the study communities were enrolled by trained study staff and their infants followed to 28 days of age.Results Between October 2009 and March 2011, 153,728 babies were delivered and followed through day 28. Neonatal death rates ranged from 41 per 1000 births in Pakistan to 8 per 1000 in Argentina; 54% of the neonatal deaths were >37 weeks and 46% weighed 2500 g or more. Half the deaths occurred within 24 hours of delivery.Conclusion In our population-based low- and middle-income country registries, the majority of neonatal deaths occurred in babies >37 weeks' gestation and almost half weighed at least 2500 g. Most deaths occurred shortly after birth. With access to better medical care and hospitalization, especially in the intrapartum and early neonatal period, many of these neonatal deaths might be prevented.     

Interest of pregnant women in the use of SMS (short message service) text messages for the improvement of perinatal and postnatal care

Background

In Ethiopia, little is known about pregnancy among rural women. Proper maternal health care depends on clear understanding of the reproductive health situation. The objective of this study was to identify predictors of unintended pregnancy in rural eastern Ethiopia.

Methodology

This study was part of pregnancy surveillance at Kersa Demographic Surveillance and Health Research Center, East Ethiopia. Pregnant women were assessed whether their current pregnancy was intended or not. Data were collected by lay interviewers using uniform questionnaire. Odds Ratio, with 95% confidence interval using multiple and multinomial logistic regression were calculated to detect level of significance.

Results

Unintended pregnancy was reported by 27.9% (578/2072) of the study subjects. Out of which, 440 were mistimed and 138 were not wanted. Unintended pregnancy was associated with family wealth status (OR 1.47; 95% CI 1.14, 1.90), high parity (7 +) (OR 5.18; 95% CI 3.31, 8.12), and a longer estimated time to walk to the nearest health care facility (OR 2.24; 95% CI: 1.49, 3.39). In the multinomial regression, women from poor family reported that their pregnancy was mistimed (OR 1.69; 95% CI 1.27, 2.25). The longer estimated time (80 + minutes) to walk to the nearest health care facility influenced the occurrence of mistimed pregnancy (OR 2.58; 95% CI: 1.65, 4.02). High parity (7+) showed a strong association to mistimed and unwanted pregnancies (OR 3.11; 95% CI 1.87, 5.12) and (OR 14.34; 95% CI 5.72, 35.98), respectively.

Conclusions

The economy of the family, parity, and walking distance to the nearest health care institution are strong predictors of unintended pregnancy. In order to reduce the high rate of unintended pregnancy Efforts to reach rural women with family planning services should be strengthened.     

Antenatal corticosteroids trial in preterm births to increase neonatal survival in developing countries: study protocol

Background

Preterm birth is a major cause of neonatal mortality, responsible for 28% of neonatal deaths overall. The administration of antenatal corticosteroids to women at high risk of preterm birth is a powerful perinatal intervention to reduce neonatal mortality in resource rich environments. The effect of antenatal steroids to reduce mortality and morbidity among preterm infants in hospital settings in developed countries with high utilization is well established, yet they are not routinely used in developing countries. The impact of increasing antenatal steroid use in hospital or community settings with low utilization rates and high infant mortality among premature infants due to lack of specialized services has not been well researched. There is currently no clear evidence about the safety of antenatal corticosteroid use for community-level births.

Methods

We hypothesize that a multi country, two-arm, parallel cluster randomized controlled trial to evaluate whether a multifaceted intervention to increase the use of antenatal corticosteroids, including components to improve the identification of pregnancies at high risk of preterm birth and providing and facilitating the appropriate use of steroids, will reduce neonatal mortality at 28 days of life in preterm newborns, compared with the standard delivery of care in selected populations of six countries. 102 clusters in Argentina, Guatemala, Kenya, India, Pakistan, and Zambia will be randomized, and around 60,000 women and newborns will be enrolled. Kits containing vials of dexamethasone, syringes, gloves, and instructions for administration will be distributed. Improving the identification of women at high risk of preterm birth will be done by (1) diffusing recommendations for antenatal corticosteroids use to health providers, (2) training health providers on identification of women at high risk of preterm birth, (3) providing reminders to health providers on the use of the kits, and (4) using a color-coded tape to measure uterine height to estimate gestational age in women with unknown gestational age. In both intervention and control clusters, health providers will be trained in essential newborn care for low birth weight babies. The primary outcome is neonatal mortality at 28 days of life in preterm infants.

Trial registration

ClinicalTrials.gov. Identifier: NCT01084096     

Womens' opinions on antenatal care in developing countries: results of a study in Cuba, Thailand, Saudi Arabia and Argentina

Background

The results of a qualitative study carried out in four developing countries (Cuba, Thailand, Saudi Arabia and Argentina) are presented. The study was conducted in the context of a randomised controlled trial to test the benefits of a new antenatal care protocol that reduced the number of visits to the doctor, rationalised the application of technology, and improved the provision of information to women in relation to the traditional protocol applied in each country.

Methods

Through focus groups discussions we were able to assess the concepts and expectations underlying women's evaluation of concepts and experiences of the care received in antenatal care clinics. 164 women participated in 24 focus groups discussion in all countries.

Results

Three areas are particularly addressed in this paper: a) concepts about pregnancy and health care, b) experience with health services and health providers, and c) opinions about the modified Antenatal Care (ANC) programme. In all three topics similarities were identified as well as particular opinions related to country specific social and cultural values. In general women have a positive view of the new ANC protocol, particularly regarding the information they receive. However, controversial issues emerged such as the reduction in the number of visits, particularly in Cuba where women are used to have 18 ANC visits in one pregnancy period.

Conclusion

Recommendations to improve ANC services performance are being proposed. Any country interested in the application of a new ANC protocol should regard the opinion and acceptability of women towards changes.     

The Cochrane Library review titles that are important to users of health care,a Cochrane Consumer Network project

Background The Cochrane Consumer Network is an internet‐based community of international users of health care contributing to the work of The Cochrane Collaboration, whose mission is to inform healthcare decision making through development of systematic reviews of best evidence on healthcare interventions. Objective To prioritize existing review titles listed on The Cochrane Library from a healthcare user perspective, with particular emphasis on patients, carers and health consumers. Design An online survey was developed and after piloting was made available internationally. The broad dissemination strategy targeted Consumer Network members and Cochrane Review Group editorial staff to identify champions who notified patient support groups and participated in snowballing. The first part of the survey defined criteria that could be applied to review titles and asked survey respondents to rank them. The second part asked respondents to select a health area and prioritize review titles that were of importance to them. Each health area corresponded to a Cochrane Review Group. Results and discussion Sufficient responses were obtained from 522 valid responses to prioritize review topics in 19 health areas. A total of 321 respondents completed the titles assessment. The types of prioritized interventions were determined by the health area. An important observation was the emphasis on lifestyle and non‐medication therapies in many of the included health areas. The clearest exception to this broad observation was where acute care is required such as antibiotics for acute respiratory tract and HIV‐associated infections and for cardiac conditions. For some cancers, advanced cancer interventions were prioritized. The most important criteria were for the title to convey a clear meaning and the title conveyed that the review would have an impact on health and well‐being. The least important criteria were that the topic was newsworthy or prioritized in the healthcare system. Conclusion This project was able to identify priority Cochrane review topics for users of health care in 19 of the 50 areas of health care covered by The Cochrane Collaboration. Reviews addressing lifestyle and non‐medical interventions were strongly represented in the prioritized review titles. These findings highlight the importance of developing readable, informative lay summaries to support evidence‐based decision making by healthcare users.