A risk prediction model for the assessment and triage of women with hypertensive disorders of pregnancy in low-resourced settings: the miniPIERS (Pre-eclampsia Integrated Estimate of RiSk) multi-country prospective cohort study.

BACKGROUND: Pre-eclampsia/eclampsia are leading causes of maternal mortality and morbidity, particularly in low- and middle- income countries (LMICs). We developed the miniPIERS risk prediction model to provide a simple, evidence-based tool to identify pregnant women in LMICs at increased risk of death or major hypertensive-related complications. METHODS AND FINDINGS: From 1 July 2008 to 31 March 2012, in five LMICs, data were collected prospectively on 2,081 women with any hypertensive disorder of pregnancy admitted to a participating centre. Candidate predictors collected within 24 hours of admission were entered into a step-wise backward elimination logistic regression model to predict a composite adverse maternal outcome within 48 hours of admission. Model internal validation was accomplished by bootstrapping and external validation was completed using data from 1,300 women in the Pre-eclampsia Integrated Estimate of RiSk (fullPIERS) dataset. Predictive performance was assessed for calibration, discrimination, and stratification capacity. The final miniPIERS model included: parity (nulliparous versus multiparous); gestational age on admission; headache/visual disturbances; chest pain/dyspnoea; vaginal bleeding with abdominal pain; systolic blood pressure; and dipstick proteinuria. The miniPIERS model was well-calibrated and had an area under the receiver operating characteristic curve (AUC ROC) of 0.768 (95% CI 0.735-0.801) with an average optimism of 0.037. External validation AUC ROC was 0.713 (95% CI 0.658-0.768). A predicted probability ≥25% to define a positive test classified women with 85.5% accuracy. Limitations of this study include the composite outcome and the broad inclusion criteria of any hypertensive disorder of pregnancy. This broad approach was used to optimize model generalizability. CONCLUSIONS: The miniPIERS model shows reasonable ability to identify women at increased risk of adverse maternal outcomes associated with the hypertensive disorders of pregnancy. It could be used in LMICs to identify women who would benefit most from interventions such as magnesium sulphate, antihypertensives, or transportation to a higher level of care

Folate catabolites in spot urine as non-invasive biomarkers of folate status during habitual intake and folic acid supplementation.

Folate status, as reflected by red blood cell (RCF) and plasma folates (PF), is related to health and disease risk. Folate degradation products para-aminobenzoylglutamate (pABG) and para-acetamidobenzoylglutamate (apABG) in 24 hour urine have recently been shown to correlate with blood folate. Since blood sampling and collection of 24 hour urine are cumbersome, we investigated whether the determination of urinary folate catabolites in fasted spot urine is a suitable non-invasive biomarker for folate status in subjects before and during folic acid supplementation. Immediate effects of oral folic acid bolus intake on urinary folate catabolites were assessed in a short-term pre-study. In the main study we included 53 healthy men. Of these, 29 were selected for a 12 week folic acid supplementation (400 µg). Blood, 24 hour and spot urine were collected at baseline and after 6 and 12 weeks and PF, RCF, urinary apABG and pABG were determined. Intake of a 400 µg folic acid bolus resulted in immediate increase of urinary catabolites. In the main study pABG and apABG concentrations in spot urine correlated well with their excretion in 24 hour urine. In healthy men consuming habitual diet, pABG showed closer correlation with PF (rs = 0.676) and RCF (rs = 0.649) than apABG (rs = 0.264, ns and 0.543). Supplementation led to significantly increased folate in plasma and red cells as well as elevated urinary folate catabolites, while only pABG correlated significantly with PF (rs = 0.574) after 12 weeks. Quantification of folate catabolites in fasted spot urine seems suitable as a non-invasive alternative to blood or 24 hour urine analysis for evaluation of folate status in populations consuming habitual diet. In non-steady-state conditions (folic acid supplementation) correlations between folate marker (RCF, PF, urinary catabolites) decrease due to differing kinetics

Sub-Saharan Africa's Mothers, Newborns, and Children: Where and Why Do They Die?

In the first article in a series on maternal, newborn, and child health in sub-Saharan Africa, Joy Lawn and colleagues outline where and why deaths among mothers and children occur and what known interventions can be employed to prevent these deaths

The Changes in Maternal Mortality in 1000 Counties in Mid-Western China by a Government-Initiated Intervention

BACKGROUND: Since 2000, the Chinese government has implemented an intervention program to reduce maternal mortality and eliminate neonatal tetanus in accordance with the Millennium Development Goals 5. To assess the effectiveness of this intervention program, we analyzed the level, trend and reasons defining the maternal mortality ratio (MMR) in the 1,000 priority counties before and after implementation of the intervention between 1999 and 2007. METHODOLOGY/PRINCIPAL FINDINGS: The data was obtained from the National Maternal and Child Health Routine Reporting System. The intervention included providing basic and emergency obstetric equipment and supplies to local medical hospitals, and also included providing professional training to local obstetric doctors, development of obstetric emergency centers and "green channel" express referral networks, reducing or waiving the cost of hospital delivery, and conducting community health education. Based on the initiation time of the intervention and the level of poverty, 1,000 counties, containing a total population of 300 million, were categorized into three groups. MMR significantly decreased by about 50%, with an average reduction rate of 9.24%, 16.06%, and 18.61% per year in the three county groups, respectively. The hospital delivery rate significantly increased. Obstetric hemorrhage was the leading cause of maternal deaths and significantly declined, with an average decrease in the MMR of 11.25%, 18.03%, and 24.90% per year, respectively. The magnitude of the MMR, the average reduction rate of the MMR, and the occurrence of the leading causes of death were closely associated with the percentage of poverty. CONCLUSIONS/SIGNIFICANCE: The intervention program implemented by the Chinese government has significantly reduced the MMR in mid-western China, suggesting that well-targeted interventions could be an efficient strategy to reducing MMR in resource-poor areas. Reduction of the MMR not only depends on conducting proven interventions, but also relies on economic development in rural areas with a high burden of maternal death

China's human resources for maternal and child health:a national sampling survey

Background: In order to achieve the Millennium Development Goals (MDG) 4 and 5, the Chinese Government has invested greatly in improving maternal and child health (MCH) with impressive results. However, one of the most important barriers for further improvement is the uneven distribution of MCH human resources. There is little information about the distribution, quantity and capacity of the Chinese MCH human resources and we sought to investigate this. Methods: Cities at prefectural level were selected by random cluster sampling. All medical and health institutions providing MCH-related services in the sampled areas were investigated using a structured questionnaire. The data were weighted based on the proportion of the sampled districts/cities. Amount, proportions and numbers per 10,000 population of MCH human resources were estimated in order to reveal the quantity of the Chinese MCH human resources. The capacity of MCH human resources was evaluated by analyzing data on the education level and professional skills of the staff. Results: There were 77,248 MCH workers in China in 2010. In general, 67.6 % and 71.9 % of the women's and children's health care professionals had an associate degree or higher, whereas around 30 % had only high-school or lower degrees. More than 40 % of the women's health workers were capable of providing skilled birth attendance, but these proportions varied between different institutions and locations. Conclusions: Evidence from this study highlights that Chinese MCH human resources are not in shortage in the national level. However, the quantity and capacity of MCH human resources are not evenly distributed among different institutions and locations. Finally there is a need in the improvement of the MCH services by improving the quality of MCH human resources.UNICEFSCI(E)[email protected]

Community health and medical provision: impact on neonates (the CHAMPION trial)

BACKGROUND: The trial aims to evaluate whether neonatal mortality can be reduced through systemic changes to the provision and promotion of healthcare. Neonatal mortality rates in India are high compared to other low income countries, and there is a wide variation of rates across regions. There is evidence that relatively inexpensive interventions may be able to prevent up to 75% of these deaths. One area with a particularly high rate is Mahabubnagar District in Andhra Pradesh, where neonatal mortality is estimated to be in the region of 4-9%. The area suffers from a vicious cycle of both poor supply of and small demand for health care services. The trial will assess whether a package of interventions to facilitate systemic changes to the provision and promotion of healthcare may be able to substantially reduce neonatal mortality in this area and be cost-effective. If successful, the trial is designed so that it should be possible to substantially scale up the project in regions with similarly high neonatal mortality throughout Andhra Pradesh and elsewhere. METHODS/DESIGN: This trial will be a cluster-randomised controlled trial involving 464 villages in Mahabubnagar District. The package of interventions will first be introduced in half of the villages with the others serving as controls. The trial will run for a period of three years. The intervention in the trial has two key elements: a community health promotion campaign and a system to contract out healthcare to non-public institutions. The health promotion campaign will include a health education campaign, participatory discussion groups, training of village health workers and midwives, and improved coordination of antenatal services. The intervention group will also have subsidized access to pregnancy-related healthcare services at non-public lth centres (NPHCs). The primary outcome of the trial will be neonatal mortality. Secondary outcomes will include age at and cause of neonatal death, neonatal morbidity, maternal mortality and morbidity, health service usage, costs and several process and knowledge outcomes. DISCUSSION: The trial will be run by independent research and service delivery arms and supervised by a trial steering committee. A data monitoring committee will be put in place to monitor the trial and recommend stopping/continuation according to a Peto-Haybittle rule. The primary publication for the trial will follow CONSORT guidelines for cluster randomised controlled trials. Criteria for authorship of all papers, presentations and reports resulting from the study will conform to ICMJE standards

Sustainable food security in India—Domestic production and macronutrient availability

<div><p>India has been perceived as a development enigma: Recent rates of economic growth have not been matched by similar rates in health and nutritional improvements. To meet the second Sustainable Development Goal (SDG2) of achieving zero hunger by 2030, India faces a substantial challenge in meeting basic nutritional needs in addition to addressing population, environmental and dietary pressures. Here we have mapped—for the first time—the Indian food system from crop production to household-level availability across three key macronutrients categories of ‘calories’, ‘digestible protein’ and ‘fat’. To better understand the potential of reduced food chain losses and improved crop yields to close future food deficits, scenario analysis was conducted to 2030 and 2050. Under India’s current self-sufficiency model, our analysis indicates severe shortfalls in availability of all macronutrients across a large proportion (>60%) of the Indian population. The extent of projected shortfalls continues to grow such that, even in ambitious waste reduction and yield scenarios, enhanced domestic production alone will be inadequate in closing the nutrition supply gap. We suggest that to meet SDG2 India will need to take a combined approach of optimising domestic production and increasing its participation in global trade.</p></div

Acceptability of evidence-based neonatal care practices in rural Uganda – implications for programming

<p>Abstract</p> <p>Background</p> <p>Although evidence-based interventions to reach the Millennium Development Goals for Maternal and Neonatal mortality reduction exist, they have not yet been operationalised and scaled up in Sub-Saharan African cultural and health systems. A key concern is whether these internationally recommended practices are acceptable and will be demanded by the target community. We explored the acceptability of these interventions in two rural districts of Uganda.</p> <p>Methods</p> <p>We conducted 10 focus group discussions consisting of mothers, fathers, grand parents and child minders (older children who take care of other children). We also did 10 key informant interviews with health workers and traditional birth attendants.</p> <p>Results</p> <p>Most maternal and newborn recommended practices are acceptable to both the community and to health service providers. However, health system and community barriers were prevalent and will need to be overcome for better neonatal outcomes. Pregnant women did not comprehend the importance of attending antenatal care early or more than once unless they felt ill. Women prefer to deliver in health facilities but most do not do so because they cannot afford the cost of drugs and supplies which are demanded in a situation of poverty and limited male support. Postnatal care is non-existent. For the newborn, delayed bathing and putting nothing on the umbilical cord were neither acceptable to parents nor to health providers, requiring negotiation of alternative practices.</p> <p>Conclusion</p> <p>The recommended maternal-newborn practices are generally acceptable to the community and health service providers, but often are not practiced due to health systems and community barriers. Communities associate the need for antenatal care attendance with feeling ill, and postnatal care is non-existent in this region. Health promotion programs to improve newborn care must prioritize postnatal care, and take into account the local socio-cultural situation and health systems barriers including the financial burden. Male involvement and promotion of waiting shelters at selected health units should be considered in order to increase access to supervised deliveries. Scale-up of the evidence based practices for maternal-neonatal health in Sub-Saharan Africa should follow rapid appraisal and adaptation of intervention packages to address the local health system and socio-cultural situation.</p