Articles

Trends of caesarean delivery from 2008 to 2017, Mexico

Caesarean delivery rates in Mexico are among the highest in the world. Given heightened public and professional awareness of this problem and the updated 2014 national guidelines to reduce the frequency of caesarean delivery, the authors analysed trends in caesarean delivery by type of facility in Mexico from 2008 to 2017. Findings suggest that since 2014, rates of caesarean delivery have fallen slightly in all sectors, but they remain high at 45.5%. Policies with appropriate interventions are needed to reduce the caesarean delivery rate in Mexico, particularly in private-sector hospitals.

Screening for HIV Infection in Pregnant Women: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

The US Preventive Services Task Force (USPSTF) previously found strong evidence that prenatal HIV screening reduced risk of mother-to-child transmission. The previous evidence review was conducted in 2012. Findings suggest that combination ART was highly effective at reducing risk of mother-to-child HIV transmission. Use of certain ART regimens during pregnancy was associated with increased risk of harms that may be mitigated by selection of ART regimen. The 2012 review found that avoidance of breastfeeding and cesarean delivery in women with viremia also reduced risk of transmission and that prenatal screening accurately diagnosed HIV infection.

Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial

The authors aimed to investigate whether antibiotic prophylaxis prevented maternal infection after operative vaginal birth. In a blinded, randomised controlled trial done at 27 UK obstetric units, women (aged ≥16 years) were allocated to receive a single dose of intravenous amoxicillin and clavulanic acid or placebo (saline) following operative vaginal birth at 36 weeks gestation or later. The primary outcome was confirmed or suspected maternal infection within 6 weeks of delivery defined by a new prescription of antibiotics for specific indications, confirmed systemic infection on culture, or endometritis. This trial shows benefit of a single dose of prophylactic antibiotic after operative vaginal birth and guidance from WHO and other national organisations should be changed to reflect this.

Meeting the SDG challenge to end fistula and preventable childbirth-related morbidity and mortality

Lack of safe, affordable, medically indicated caesarean delivery is a primary contributor to global health inequity. In low-income and middle-income countries (LMICs), it perpetuates preventable morbidity and mortality caused by prolonged or obstructed labour.  Adequate intervention alone would avert 1 million disability-adjusted life-years (DALYs), with a median benefit-to-cost ratio of 6·0 at US$304 per DALY averted, reflecting an eradicable burden of disease that undermines sustainable development, economic growth, and human rights.

National, regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: a systematic analysis

The authors aimed to assist in setting a baseline against which to assess progress towards the achievement of the World Health Assembly targets for reductions in low birth weight (LBW) prevalence. The authors collated data on 1447 country-years of birthweight data (281 million births) for 148 countries of 195 UN member states (47 countries had no data meeting inclusion criteria). The estimated worldwide LBW prevalence in 2015 was 14·6% compared with 17·5% in 2000 (average annual reduction rate 1·23%). In 2015, an estimated 20·5 million livebirths were LBW, 91% from low-and-middle income countries, mainly southern Asia (48%) and sub-Saharan Africa (24%).

A Randomized Trial of Progesterone in Women with Bleeding in Early Pregnancy

The authors conducted a multicenter, randomized, double-blind, placebo-controlled trial to evaluate progesterone, as compared with placebo, in women with vaginal bleeding in early pregnancy. The findings suggest that among women with bleeding in early pregnancy, progesterone therapy administered during the first trimester did not result in a significantly higher incidence of live births than placebo.

Association of Gestational Weight Gain With Adverse Maternal and Infant Outcomes

The objective of the study was to examine the association of ranges of gestational weight gain with risk of adverse maternal and infant outcomes and estimate optimal gestational weight gain ranges across prepregnancy body mass index categories. Individual participant-level meta-analysis using data from 196 670 participants within 25 cohort studies from Europe and North America (main study sample) was conducted. In this meta-analysis of pooled individual participant data from 25 cohort studies, the risk for adverse maternal and infant outcomes varied by gestational weight gain and across the range of prepregnancy weights. The estimates of optimal gestational weight gain may inform prenatal counseling; however, the optimal gestational weight gain ranges had limited predictive value for the outcomes assessed.

An mHealth SMS intervention on Postpartum Contraceptive Use Among Women and Couples in Kenya: A Randomized Controlled Trial

The objective of this study was to assess the effect of 2-way short message service (SMS) with a nurse on postpartum contraceptive use among individual women and couples. The authors conducted a randomized controlled trial at 2 public hospitals in western Kenya. Findings suggest that the two-way SMS with a nurse, including optional male participation, increased postpartum contraceptive use.

Effect of Addition of an Intimate Partner Violence Intervention to a Nurse Home Visitation Program on Maternal Quality of Life A Randomized Clinical Trial

This cluster randomised trial assessed whether augmentation of a nurse home visitation program with an intimate partner violence intervention, starting in pregnancy, compared with the home visitation program alone, leads to improved maternal quality of life at 24 months after infant delivery? The trial included 492 pregnant women, randomization to the augmented program compared with nurse home visitation alone resulted in maternal quality-of-life scores at 24 months postdelivery of 311.3 vs 316.2 (measured using the WHOQOL-BREF scale; range, 0-400)—a difference that was not statistically significant. These findings do not support augmenting a nurse home visitation program with this complex, multifaceted intimate partner violence intervention.

What maternal morbidities are and what they mean for women: A thematic analysis of twenty years of qualitative research in low and lower-middle income countries

As part of the WHO’s Maternal Morbidity Working Group’s efforts to define and measure maternal morbidity, the authors carried out a thematic analysis of the qualitative literature published between 1998 and 2017 on how women experience maternal morbidity in low and lower-middle income countries. Analysis of the 71 papers included in this study shows that women’s status, their marital relationships, cultural attitudes towards fertility and social responses to infertility and pregnancy trauma are fundamental to determining how they will experience morbidity in the pregnancy and postpartum periods. 

Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis

Universal and timely access to a caesarean section is a key requirement for safe childbirth. This review identified the burden of maternal and perinatal mortality and morbidity, and the risk factors following caesarean sections in low-income and middle-income countries (LMICs). The review included 196 studies from 67 LMICs. The risk of maternal death in women who had a caesarean section was 7·6 per 1000 procedures; the highest burden was in sub-Saharan Africa (10·9 per 1000). A quarter of all women who died in LMICs had undergone a caesarean section. Maternal deaths and perinatal deaths following caesarean sections are disproportionately high in LMICs. The timing and urgency of caesarean section pose major risks.

Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzania

This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home. A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC.

Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study

A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. Findings suggest that maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa.

Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools

The authors aimed to assess the capacity of globally used, large-scale facility assessment tools to measure quality of maternal and newborn care as per the WHO framework. Findings suggest that existing facility assessment tools provide a valuable way to assess quality of maternal and newborn care as one element within the national measurement toolkit. Guidance is clearly needed on priority measures and for better harmonisation across tools to reduce measurement burden and increase data use for quality improvement. Targeted development of measurement modules to address important gaps is a key priority for research.

Q&A with research midwife Arancha de la Horra

Assessing the role of women's autonomy and acceptability of intimate-partner violence in maternal health-care utilization in 63 low- and middle-income countries.

This study investigates the associations between women's autonomy and attitudes toward the acceptability of intimate-partner violence against women (IPVAW) and maternal health-care utilization outcomes. The findings suggest that strong and significant associations exist between autonomy, acceptability of IPVAW and utilization of maternal health-care services.

Effect of a novel vital sign device on maternal mortality and morbidity in low-resource settings: a pragmatic, stepped-wedge, cluster-randomised controlled trial

The primary aim of this trial was to determine whether implementation of the CRADLE Vital Sign Alert and an education package into community and facility maternity care in low-resource settings could reduce a composite of all-cause maternal mortality or major morbidity (eclampsia and hysterectomy) across Africa, India, and Haiti. There was an absolute 8% reduction in primary outcome during the trial, with no change in resources or staffing, but this reduction could not be directly attributed to the intervention due to variability. The authors encountered unanticipated methodological challenges with this trial design, which can provide valuable learning for future research and inform the trial design of future international stepped-wedge trials.

Webinar: Pregnant Women & Vaccines Against Emerging Epidemic Threats: Ethics Guidance for Preparedness, Research, and Response, 5 March 2019

Engagement Strategies: The Development of Mahidol Oxford Tropical Medicine Research Unit’s (MORU) Community and Stakeholder Engagement Strategy

Neurodevelopmental milestones and associated behaviours are similar among healthy children across diverse geographical locations

The latest findings from the international INTERGROWTH-21^st Project, that has monitored healthy, urban children from educated families across four continents from early pregnancy to 2 years of age, show that human neurodevelopment is not influenced by the colour of an individual’s skin.