Neonatal Near Miss: the need for a standard definition and appropriate criteria and the rationale for a prospective surveillance system

In Latin American, there is currently a regional action with the main purposes of putting the concept of severe neonatal morbidity in practice and formulating proposals for interventions. A general overview of neonatal health conditions, including morbidity and mortality, is provided to update regional knowledge on the topic. An example of the development and implementation of the concept of maternal near miss is also provided, followed by results from a systematic review covering all previously published studies on Neonatal Near Miss. Finally, some proposals for building a common concept on the topic and for launching a prospective surveillance study are presented. A Neonatal Near Miss is a neonate who had a severe morbidity (organ dysfunction or failure) but who survived this condition within the first 27 days of life. The pragmatic criteria recommended to be used are as follows: birth weight below 1700 g, Apgar score below 7 at 5 minutes of life and gestational age below 33 weeks. As a proxy for organ dysfunction, the following management criteria are also confirmed: parenteral therapeutic antibiotics; nasal continuous positive airway pressure; any intubation during the first 27 days of life; phototherapy within the first 24 h of life; cardiopulmonary resuscitation; the use of vasoactive drugs, anticonvulsants, surfactants, blood products and steroids for refractory hypoglycemia and any surgical procedure. Although this study starts from a regional perspective, this topic is clearly globally relevant. All nations, especially low and middle-income countries, could benefit from the proposed standardization

Neonatal near miss: the need for a standard definition and appropriate criteria and the rationale for a prospective surveillance system

In Latin American, there is currently a regional action with the main purposes of putting the concept of severe neonatal morbidity in practice and formulating proposals for interventions. A general overview of neonatal health conditions, including morbidity and mortality, is provided to update regional knowledge on the topic. An example of the development and implementation of the concept of maternal near miss is also provided, followed by results from a systematic review covering all previously published studies on Neonatal Near Miss. Finally, some proposals for building a common concept on the topic and for launching a prospective surveillance study are presented. A Neonatal Near Miss is a neonate who had a severe morbidity (organ dysfunction or failure) but who survived this condition within the first 27 days of life. The pragmatic criteria recommended to be used are as follows: birth weight below 1700 g, Apgar score below 7 at 5 minutes of life and gestational age below 33 weeks. As a proxy for organ dysfunction, the following management criteria are also confirmed: parenteral therapeutic antibiotics; nasal continuous positive airway pressure; any intubation during the first 27 days of life; phototherapy within the first 24 h of life; cardiopulmonary resuscitation; the use of vasoactive drugs, anticonvulsants, surfactants, blood products and steroids for refractory hypoglycemia and any surgical procedure. Although this study starts from a regional perspective, this topic is clearly globally relevant. All nations, especially low and middle-income countries, could benefit from the proposed standardization701282082

Neonatal Near Miss: A Systematic Review.

The concept of neonatal near miss has been proposed as a tool for assessment of quality of care in neonates who suffered any life-threatening condition. However, there are no internationally agreed concepts or criteria for defining or identifying neonatal near miss. The purpose of this study was to perform a systematic review of studies and markers that are able to identify neonatal near miss cases and predict neonatal mortality. Electronic searches were performed in the Medline, Embase and Scielo databases, with no time or language restriction, until December 2014. The term neonatal near miss was used alone or in combination with terms related to neonatal morbidity/mortality and neonatal severity scores. Study selection criteria involved three steps: title, abstract and full text of the articles. Two researchers performed study selection and data extraction independently. Heterogeneity of study results did not permit the performance of meta-analysis. Following the inclusion and exclusion criteria adopted, only four articles were selected. Preterm and perinatal asphyxia were used as near miss markers in all studies. Health indicators on neonatal morbidity and mortality were extracted or estimated. The neonatal near miss rate was 2.6 to 8 times higher than the neonatal mortality rate. Pragmatic and management criteria are used to help develop the neonatal near miss concept. The most severe cases are identified and mortality is predicted with these criteria. Furthermore, the near miss concept can be used as a tool for evaluating neonatal care. It is the first step in building management strategies to reduce mortality and long-term sequelae.1532

Optimal Timing of Delivery among Low-Risk Women with Prior Caesarean Section: A Secondary Analysis of the WHO Multicountry Survey on Maternal and Newborn Health

ObjectiveTo investigate optimal timing of elective repeat caesarean section among low-risk pregnant women with prior caesarean section in a multicountry sample from largely low- and middle-income countries.DesignSecondary analysis of a cross-sectional study.SettingTwenty-nine countries from the World Health Organization Multicountry Survey on Maternal and Newborn Health.Population29,647 women with prior caesarean section and no pregnancy complications in their current pregnancy who delivered a term singleton (live birth and stillbirth) at gestational age 37–41 weeks by pre-labour caesarean section, intra-partum caesarean section, or vaginal birth following spontaneous onset of labour.MethodsWe compared the rate of short-term adverse maternal and newborn outcomes following pre-labour caesarean section at a given gestational age, to those following ongoing pregnancies beyond that gestational age.Main Outcome MeasuresSevere maternal outcomes, neonatal morbidity, and intra-hospital early neonatal mortality.ResultsOdds of neonatal morbidity and intra-hospital early neonatal mortality were 0.48 (95% confidence interval [CI] 0.39–0.60) and 0.31 (95% CI 0.16–0.58) times lower for ongoing pregnancies compared to pre-labour caesarean section at 37 weeks. We did not find any significant change in the risk of severe maternal outcomes between pre-labour caesarean section at a given gestational age and ongoing pregnancies beyond that gestational age.ConclusionsElective repeat caesarean section at 37 weeks had higher risk of neonatal morbidity and mortality compared to ongoing pregnancy, however risks at later gestational ages did not differ between groups

Risk factors and adverse perinatal outcomes among term and preterm infants born small-for-gestational-age: secondary analyses of the WHO multi-country survey on maternal and newborn health

BACKGROUND Small for gestational age (SGA) is not only a major indicator of perinatal mortality and morbidity, but also the morbidity risks in later in life. We aim to estimate the association between the birth of SGA infants and the risk factors and adverse perinatal outcomes among twenty-nine countries in Africa, Latin America, the Middle East and Asia in 359 health facilities in 2010–11. METHODS We analysed facility-based, cross-sectional data from the WHO Multi-country Survey on Maternal and Newborn Health. We constructed multilevel logistic regression models with random effects for facilities and countries to estimate the risk factors for SGA infants using country-specific birthweight reference standards in preterm and term delivery, and SGA’s association with adverse perinatal outcomes. We compared the risks and adverse perinatal outcomes with appropriate for gestational age (AGA) infants categorized by preterm and term delivery. RESULTS A total of 295,829 singleton infants delivered were analysed. The overall prevalence of SGA was highest in Cambodia (18.8%), Nepal (17.9%), the Occupied Palestinian Territory (16.1%), and Japan (16.0%), while the lowest was observed in Afghanistan (4.8%), Uganda (6.6%) and Thailand (9.7%). The risk of preterm SGA infants was significantly higher among nulliparous mothers and mothers with chronic hypertension and preeclampsia/eclampsia (aOR: 2.89; 95% CI: 2.55–3.28) compared with AGA infants. Higher risks of term SGA were observed among sociodemographic factors and women with preeclampsia/eclampsia, anaemia and other medical conditions. Multiparity (> = 3) (AOR: 0.88; 95% CI: 0.83–0.92) was a protective factor for term SGA. The risk of perinatal mortality was significantly higher in preterm SGA deliveries in low to high HDI countries. CONCLUSION Preterm SGA is associated with medical conditions related to preeclampsia, but not with sociodemographic status. Term SGA is associated with sociodemographic status and various medical conditions.Erika Ota, Togoobaatar Ganchimeg, Naho Morisaki, Joshua P. Vogel, Cynthia Pileggi, Eduardo Ortiz-Panozo, Joa, o P. Souza, Rintaro Mori, on behalf of the WHO Multi-Country Survey on Maternal and Newborn Health Research Networ

Prevalence of early initiation of breastfeeding and determinants of delayed initiation of breastfeeding: secondary analysis of the WHO Global Survey

Early initiation of breastfeeding (EIBF) within 1 hour of birth can decrease neonatal death. However, the prevalence of EIBF is approximately 50% in many developing countries, and data remains unavailable for some countries. We conducted a secondary analysis using the WHO Global Survey on Maternal and Perinatal Health to identify factors hampering EIBF. We described the coverage of EIBF among 373 health facilities for singleton neonates for whom breastfeeding was initiated after birth. Maternal and facility characteristics of EIBF were compared to those of breastfeeding >1 hour after birth, and multiple logistic regression analysis was performed. In total, 244,569 singleton live births without severe adverse outcomes were analysed. The EIBF prevalence varied widely among countries and ranged from 17.7% to 98.4% (average, 57.6%). There was less intra-country variation for BFI <24 hours. After adjustment, EIBF was significantly lower among women with complications during pregnancy and caesarean delivery. Globally, EIBF varied considerably across countries. Maternal complications during pregnancy, caesarean delivery and absence of postnatal/neonatal care guidelines at hospitals may affect EIBF. Our findings suggest that to better promote EIBF, special support for breastfeeding promotion is needed for women with complications during pregnancy and those who deliver by caesarean section

Antenatal corticosteroids for women at risk of imminent preterm birth in low-resource countries: the case for equipoise and the need for efficacy trials

The scientific basis for antenatal corticosteroids (ACS) for women at risk of preterm birth has rapidly changed in recent years. Two landmark trials—the Antenatal Corticosteroid Trial and the Antenatal Late Preterm Steroids Trial—have challenged the long-held assumptions on the comparative health benefits and harms regarding the use of ACS for preterm birth across all levels of care and contexts, including resource-limited settings. Researchers, clinicians, programme managers, policymakers and donors working in low-income and middle-income countries now face challenging questions of whether, where and how ACS can be used to optimise outcomes for both women and preterm newborns. In this article, we briefly present an appraisal of the current evidence around ACS, how these findings informed WHO’s current recommendations on ACS use, and the knowledge gaps that have emerged in the light of new trial evidence. Critical considerations in the generalisability of the available evidence demonstrate that a true state of clinical equipoise exists for this treatment option in low-resource settings. An expert group convened by WHO concluded that there is a clear need for more efficacy trials of ACS in these settings to inform clinical practice

Assessment of funnel plot asymmetry and publication bias in reproductive health meta-analyses: an analytic survey

BACKGROUND: Despite efforts to assure high methodological standards, systematic reviews may be affected by publication bias. The objective of this study was to evaluate the occurrence of publication bias in a collection of high quality systematic reviews on reproductive health. METHODS: Systematic reviews included in the Reproductive Health Library (RHL), issue No 9, were assessed. Funnel plot was used to assess meta-analyses containing 10 or more trials reporting a binary outcome. A funnel plot, the estimated number of missing studies and the adjusted combined effect size were obtained using the "trim and fill method". Meta-analyses results that were not considered to be robust due to a possible publication bias were submitted to a more detailed assessment. RESULTS: A total of 21 systematic reviews were assessed. The number of trials comprising each one ranged from 10 to 83 (median = 13), totaling 379 trials, whose results have been summarized. None of the reviews had reported any evaluation of publication bias or funnel plot asymmetry. Some degree of asymmetry in funnel plots was observed in 18 of the 21 meta-analyses evaluated (85.7%), with the estimated number of missing studies ranging from 1 to 18 (median = 3). Only for three meta-analyses, the conclusion could not be considered robust due to a possible publication bias. CONCLUSION: Asymmetry is a frequent finding in funnel plots of meta-analyses in reproductive health, but according to the present evaluation, less than 15% of meta-analyses report conclusions that would not be considered robust. Publication bias and other sources of asymmetry in funnel plots should be systematically addressed by reproductive health meta-analysts. Next amendments in Cochrane systematic reviews should include this type of evaluation. Further studies regarding the evolution of effect size and publication bias over time in systematic reviews in reproductive health are needed

American College of Rheumatology Provisional Criteria for Clinically Relevant Improvement in Children and Adolescents With Childhood-Onset Systemic Lupus Erythematosus

10.1002/acr.23834ARTHRITIS CARE & RESEARCH715579-59