by
Jesmin Pervin;
Allisyn Moran;
Monjur Rahman;
Abdur Razzaque;
Lynn Sibley;
Peter K. Streatfield;
Laura J. Reichenbach;
Marge Koblinsky;
Daniel Hruschka;
Anisur Rahman
Background: Antenatal Care (ANC) during pregnancy can play an important role in the uptake of evidence-based services vital to the health of women and their infants. Studies report positive effects of ANC on use of facility-based delivery and perinatal mortality. However, most existing studies are limited to cross-sectional surveys with long recall periods, and generally do not include population-based samples.
Methods: This study was conducted within the Health and Demographic Surveillance System (HDSS) of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in Matlab, Bangladesh. The HDSS area is divided into an icddr,b service area (SA) where women and children receive care from icddr,b health facilities, and a government SA where people receive care from government facilities. In 2007, a new Maternal, Neonatal, and Child Health (MNCH) program was initiated in the icddr,b SA that strengthened the ongoing maternal and child health services including ANC. We estimated the association of ANC with facility delivery and perinatal mortality using prospectively collected data from 2005 to 2009. Using a before-after study design, we also determined the role of ANC services on reduction of perinatal mortality between the periods before (2005 - 2006) and after (2008-2009) implementation of the MNCH program.
Results: Antenatal care visits were associated with increased facility-based delivery in the icddr,b and government SAs. In the icddr,b SA, the adjusted odds of perinatal mortality was about 2-times higher (odds ratio (OR) 1.91; 95% confidence intervals (CI): 1.50, 2.42) among women who received ≤1 ANC compared to women who received ≥3 ANC visits. No such association was observed in the government SA. Controlling for ANC visits substantially reduced the observed effect of the intervention on perinatal mortality (OR 0.64; 95% CI: 0.52, 0.78) to non-significance (OR 0.81; 95% CI: 0.65, 1.01), when comparing cohorts before and after the MNCH program initiation (Sobel test of mediation P < 0.001).
Conclusions: ANC visits are associated with increased uptake of facility-based delivery and improved perinatal survival in the icddr,b SA. Further testing of the icddr,b approach to simultaneously improving quality of ANC and facility delivery care is needed in the existing health system in Bangladesh and in other low-income countries to maximize health benefits to mothers and newborns.
Background: Participation in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) has been associated with lower risk of stillbirth. We hypothesized that such an association would differ by race/ethnicity because of factors associated with WIC participation that confound the association. Methods: We conducted a secondary analysis of the Stillbirth Collaborative Research Network's population-based case-control study of stillbirths and live-born controls, enrolled at delivery between March 2006 and September 2008. Weighting accounted for study design and differential consent. Five nested models using multivariable logistic regression examined whether the WIC participation/stillbirth associations were attenuated after sequential adjustment for sociodemographic, health, healthcare, socioeconomic, and behavioral factors. Models also included an interaction term for race/ethnicity x WIC. Results: In the final model, WIC participation was associated with lower adjusted odds (aOR) of stillbirth among non-Hispanic Black women (aOR: 0.34; 95% CI 0.16, 0.72) but not among non-Hispanic White (aOR: 1.69; 95% CI: 0.89, 3.20) or Hispanic women (aOR: 0.91; 95% CI 0.52, 1.52). Conclusions: Contrary to our hypotheses, control for potential confounding factors did not explain disparate findings by race/ethnicity. Rather, WIC may be most beneficial to women with the greatest risk factors for stillbirth. WIC-eligible, higher-risk women who do not participate may be missing the potential health associated benefits afforded by WIC.
BACKGROUND: Ethiopia has made steady progress in improving maternal health over the decade, yet mortality remains high. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) was a 3.5-year project aimed at developing a community-oriented model to improve maternal and newborn survival in rural Ethiopia. Two years after the project ended, we carried out a case study to explore illness recognition and care seeking for complications of pregnancy and childbirth in the project area. This paper describes the results of one component: illness narratives. METHODS: Sampling involved random selection of 12 health facilities from 6 MaNHEP project districts in Amhara and >Oromia regions, and purposive selection of cases from the facility catchment areas. The purposive sample included 17 cases of perceived excessive bleeding, 5 cases of maternal death from any cause, and witnesses to the illness events. Two-person teams facilitated the narrative interviews. Analysis included thematic content analysis of symptoms, causes, decision makers and decision-making, factors facilitating and impeding care seeking, and delineation of care-seeking steps. RESULTS: Most surviving mothers (and witnesses) perceived the symptoms and seriousness of excessive bleeding; a majority (53%) sought timely biomedical care. Three of five families of mothers who died from causes unrelated to bleeding failed to initially perceive symptoms as serious, yet all sought timely appropriate care once they did so. Many of these families took multiple steps to obtain care, leading to delays.. Health worker counseling and proximity to health services facilitated, while certain cultural norms, economic, geographic, and environmental constraints impeded care seeking. Surprisingly, poor quality of care at health facilities was not a barrier. CONCLUSION: Mothers and family caregivers are able to recognize and seek timely biomedical care for abnormal bleeding, and for less obvious symptoms of illness. These achievements can be reinforced through continued and focused health education and counseling, reduction of known barriers to care seeking, and improvements in the capacity of the health system to respond to maternal complications with high quality basic and comprehensive emergency obstetric care.
Background: Today, scientific evidence has supported the popular belief that physical activity is associated with biological health in pregnant women. A randomized controlled trial was used to assess the benefits of physical exercise during pregnancy on maternal lipids in low-income Latina women. Methods: The study included 67 nulliparous low-income Latina women in gestational weeks 16-20, randomly assigned into one of two groups: 1) The exercise group, which took part in aerobic and resistance exercise for 60min, three times a week for 12weeks, 2) The control group, which undertook their usual physical activity and prenatal care. The primary outcomes were changes in maternal blood lipids after intervention. Obstetrical and neonatal outcomes measured were type of delivery, postpartum hemorrhage, newborn and/or maternal complications', gestational age, weight gain, birth weight, foetal growth, and Apgar score. Results: Fifty women completed the study. At the end of the intervention, there were differences between groups in low-density lipoprotein levels (mean change: -8mg/dL, 95%CI -3 to -29; P < 0.001) and triglycerides (mean change: -6mg/dL, 95%CI -1 to -11; P=0.03). Also, compared with women who remained in the control group, active women showed lower complications during delivery (moderate postpartum haemorrhage) (58% compared with 75%; P < 0.05) and lower complications in newborns (e.g. cyanosis or respiratory distress) (21% compared with 46%; P < 0.001). Conclusions: An exercise programme during the second and third trimester favours less gain in low-density lipoprotein cholesterol and triglycerides fewer delivery and neonatal complications. Trial registration:NCT00741312(August 22, 2008).
Background: Vitamin B12 deficiency is associated with many adverse health outcomes and is highly prevalent worldwide. The present study assesses the prevalence and socio-demographic factors associated with vitamin B12 deficiency in a representative sample of pregnant women in Colombia.
Method: We used data from the cross-sectional, nationally representative survey (ENSIN, 2010). A total of 1.781, (13-49 years old) pregnant women were enrolled. Serum Vitamin B12 a concentration was determined by chemiluminescence and sociodemographic date was assessed by computer-assisted personal interview technology. Multivariate analyses using unordered multinomial logistic regression models were conducted in the main analysis.
Results: Vitamin B12 concentrations ranged from 45 to 1000 pg/mL (mean 299.2 pg/mL, 95 % CI 290.6 to 303.7 pg/mL). A total of 18.6 % of pregnant women had vitamin B12 concentrations below 200 pg/mL and 41.3 % had concentrations between 200 and 300 pg/mL. Being of indigenous ethnicity, living in the east and living in a rural area showed the lowest mean values (273.2 pg/mL, 270.8 pg/mL and 290.1 pg/mL, respectively). The multivariate logistic regression shows that pregnant women belonging to the indigenous ethnic group OR 2.2, (95 % CI 1.1 to 4.3), living in the pacific region (west) OR 4.4, (95 % CI 2.8 to 6.9), or national territories (south) OR 2.3, (95 % CI 1.4 to 3.7) were associated with a higher probability of serum vitamin B12 deficiency.
Conclusion: The prevalence of vitamin B12 deficiency in Colombian pregnant women is substantial. Factors associated with depletion among pregnant women should be considered for future interventions in countries experiencing nutritional transition.
Background: In most high and middle income countries across the world, at least 1:4 women give birth by cesarean section. Rates of labour induction and augmentation are rising steeply; and in some countries up to 50 % of laboring women and newborns are given antibiotics. Governments and international agencies are increasingly concerned about the clinical, economic and psychosocial effects of these interventions.
Discussion: There is emerging evidence that certain intrapartum and early neonatal interventions might affect the neonatal immune response in the longer term, and perhaps trans-generationally. Two theories lead the debate in this area. Those aligned with the hygiene (or 'Old Friends') hypothesis have examined the effect of gut microbiome colonization secondary to mode of birth and intrapartum/neonatal pharmacological interventions on immune response and epigenetic phenomena. Those working with the EPIIC (Epigenetic Impact of Childbirth) hypothesis are concerned with the effects of eustress and dys-stress on the epigenome, secondary to mode of birth and labour interventions.
Summary: This paper examines the current and emerging findings relating to childbirth and atopic/autoimmune disease from the perspective of both theories, and proposes an alliance of research effort. This is likely to accelerate the discovery of important findings arising from both approaches, and to maximize the timely understanding of the longer-term consequences of childbirth practices.
Background: Accurate estimation of gestational age is important for both clinical and public health purposes. Estimates of gestational age using fetal ultrasound measurements are considered most accurate but are frequently unavailable in low- and middle-income countries. The objective of this study was to assess the validity of last menstrual period and Farr neonatal examination estimates of gestational age, compared to ultrasound estimates, in a large cohort of women in Vietnam.
Methods: Data for this analysis come from a randomized, placebo-controlled micronutrient supplementation trial in Vietnam. We analyzed 912 women with ultrasound and prospectively-collected last menstrual period estimates of gestational age and 685 women with ultrasound and Farr estimates of gestational age. We used the Wilcoxon signed rank sum test to assess differences in gestational age estimated by last menstrual period or Farr examination compared to ultrasound and computed the intraclass correlation coefficient (ICC) and concordance correlation coefficient (CCC) to quantify agreement between methods. We computed the Kappa coefficient (κ) to quantify agreement in preterm, term and post-term classification.
Results: The median gestational age estimated by ultrasound was 273.9 days. Gestational age was slightly overestimated by last menstrual period (median 276.0 days, P < 0.001) and more greatly overestimated by Farr examination (median 286.7 days, P < 0.001). Gestational age estimates by last menstrual period and ultrasound were moderately correlated (ICC = 0.78) and concordant (CCC = 0.63), whereas gestational age estimates by Farr examination and ultrasound were weakly correlated (ICC = 0.26) and concordant (CCC = 0.05). Last menstrual period and ultrasound estimates of gestational age were within ± 14 days for 88.4% of women; Farr and ultrasound estimates were within ± 14 days for 55.8% of women. Last menstrual period and ultrasound estimates of gestational age had higher agreement in term classification (κ = 0.41) than Farr and ultrasound (κ = 0.05).
Conclusion: In this study of women in Vietnam, we found last menstrual period provided a more accurate estimate of gestational age than the Farr examination when compared to ultrasound. These findings provide useful information about the utility and accuracy of different methods to estimate gestational age and suggest last menstrual period may be preferred over Farr examination in settings where ultrasound is unavailable.
by
Matthew Bridwell;
Endang Handzel;
Michelle Hynes;
Reginald Jean-Louis;
David Fitter;
Carol Hogue;
Reynold Grand-Pierre;
Hedwige Pierre;
Bradley Pearce
Background: This study aims to determine reported prevalence of hypertensive disorders in pregnancy (HDP) and maternal and neonatal outcomes associated with these disorders among women delivering at selected hospitals across Haiti. Methods: A retrospective review of 8822 singleton deliveries between January 2012 and December 2014 was conducted at four hospitals in separate Departments across Haiti. Researchers examined the proportion of women with reported HDP (hypertension, preeclampsia, eclampsia) and the association between women with HDP and three neonatal outcomes: low birth weight, preterm birth, and stillbirths; and two maternal outcomes: placental abruption and maternal death in Hôpital Albert Schweitzer (HAS). Odds ratios for associations between HDP and perinatal outcomes at HAS were assessed using logistic regression, adjusting for potential confounders. Results: Of the 8822 singleton births included in the study, 510 (5.8%) had a reported HDP (including 285 (55.9%) preeclampsia, 119 (23.3%) eclampsia, and 106 (20.8%) hypertension). Prevalence of HDP among each hospital was: HAS (13.5%), Hôpital Immaculée Conception des Cayes (HIC) (3.2%), Fort Liberté (4.3%), and Hôpital Sacré Coeur de Milot (HSC) (3.0%). Among women at HAS with HDP, the adjusted odds of having a low birth weight baby was four times that of women without HDP (aOR 4.17, 95% CI 3.19-5.45), more than three times that for stillbirths (aOR 3.51, 95% CI 2.43-5.06), and five times as likely to result in maternal death (aOR 5.13, 95% CI 1.53-17.25). Among the three types of HDP, eclampsia was associated with the greatest odds of adverse events with five times the odds of having a low birth weight baby (aOR 5.00, 95% CI 2.84-8.79), six times the odds for stillbirths (aOR 6.34, 95% CI 3.40-11.82), and more than twelve times as likely to result in maternal death (aOR 12.70, 95% CI 2.33-69.31). Conclusions: A high prevalence of HDP was found among a cohort of Haitian mothers. HDP was associated with higher rates of adverse maternal and neonatal outcomes in HAS, which is comparable to studies of HDP conducted in high-income countries.
Background
Lactate dehydrogenase (LDH) isoenzymes are required for adenosine triphosphate production, with each of five different isoenzymes having varying proficiencies in anaerobic versus aerobic environments. With advancing pregnancy, the isoenzyme profile in uterine muscle shifts toward a more anaerobic profile, speculatively to facilitate uterine efficiency during periods of low oxygen that accompany labor contractions. Profile shifting may even occur throughout labor. Maternal serum LDH levels between 24–48 hours following delivery predominantly originate from uterine muscle, reflecting the enzymatic state of the myometrium during labor. Our purpose was to describe serum LDH isoenzymes 24–30 hours post-delivery to determine if cervical dilation rates following labor admission were associated with a particular LDH profile. We also compared differences in post-delivery LDH isoenzyme profiles between women admitted in pre-active versus established active labor.
Methods
Low-risk, nulliparous women with spontaneous labor onset were sampled (n = 91). Maternal serum LDH was measured at labor admission and 24–30 hours post-vaginal delivery. Rates of cervical dilation during the first four hours after admission were also measured. Spearman’s rho coefficients were used for association testing and t tests evaluated for group and paired-sample differences.
Results
More efficient dilation following admission was associated with decreased LDH1 (p = 0.029) and increased LDH3 and LDH4 (p = 0.017 and p = 0.017, respectively) in the post-delivery period. Women admitted in established active labor had higher relative serum levels of LDH3 (t = 2.373; p = 0.023) and LDH4 (t = 2.268; p = 0.029) and lower levels of LDH1 (t = 2.073; p = 0.045) and LDH5 (t = 2.041; p = 0.048) when compared to women admitted in pre-active labor.
Despite having similar dilatations at admission (3.4 ± 0.5 and 3.7 ± 0.6 cm, respectively), women admitted in pre-active labor had longer in-hospital labor durations (12.1 ± 4.3 vs. 5.3 ± 1.4 hours; p < 0.001) and were more likely to receive oxytocin augmentation (95.5% vs. 34.8%; p < 0.001).
Conclusions
More efficient cervical dilation following labor admission is associated with a more anaerobic maternal serum LDH profile in the post-delivery period. Since LDH profile shifting may occur throughout labor, watchful patience rather than intervention in earlier labor may allow LDH shifting within the uterus to more fully manifest. This may improve uterine efficiency during labor and decrease rates of oxytocin augmentation, thereby improving birth safety.