Epidemiology, diagnosis, and care-seeking related to risk factors for intrapartum-related fetal and neonatal death in rural Nepal

Intrapartum-related complications are the second leading cause of neonatal death. To better target this cause, this thesis examines the epidemiology of intrapartum-related mortality and morbidity in rural Nepal, and assesses the feasibility of community-based antenatal diagnosis of risk factors for intrapartum-related complications, including non-cephalic presentation, multiple gestation, and placenta previa. The research was nested in the Nepal Oil Massage Study, conducted in rural Sarlahi District, Nepal. The research consisted of several components: 1) a community-based prospective cohort study to examine the incidence of third-trimester obstetric risk factors and their associations with adverse pregnancy outcomes, 2) a community-based cross-sectional survey to understand the awareness and utilization of obstetric ultrasonography in the study area, 3) a community-based validation study to examine how accurately lower-level health workers with limited training can use portable ultrasound to detect three major risk factors of adverse intrapartum-related pregnancy outcomes: non-cephalic position, multiple gestation, and poor placental position / placenta previa, 4) in-depth interviews with mothers who recently experienced a non-cephalic birth and/or female decision-makers in their household to discuss their care-seeking behavior and risk perception toward non-cephalic presentation, and 5) focus groups with women in the community pertaining to the same topic. We observed a very high risk of adverse intrapartum-related outcomes associated with non-cephalic and multiple birth respectively. Many women who experienced these conditions were undiagnosed prior to delivery. Only about a quarter of the women in our community received an obstetric ultrasound exam during their most recent pregnancy. Lower-level health workers with limited training were able to diagnose non-cephalic position and multiple gestation with high validity using ultrasonography. Despite the very high adverse outcome rate among non-cephalic births, the perceived risk of the condition varied widely. Fetal and neonatal mortality and morbidity attributable to intrapartum-related complications have fallen at a much slower pace than those attributable to other causes. We highlighted here the potential for targeting low-prevalence, but high-risk obstetric risk factors to reduce the health burden in low-resource settings caused by intrapartum-related complications

Performance of low-literate community health workers treating severe acute malnutrition in South Sudan

No Abstract

Risk and burden of adverse intrapartum-related outcomes associated with non-cephalic and multiple birth in rural Nepal: a prospective cohort study

Objectives Intrapartum-related complications are the second leading cause of neonatal death worldwide. We estimate the community-level risk and burden of intrapartum-related fetal/neonatal mortality and morbidity associated with non-cephalic and multiple birth in rural Sarlahi District, Nepal. Design Community-based prospective cohort study. Setting Rural Sarlahi District, Nepal. Participants Pregnant women residing in the study area. Methods We collected data on maternal background characteristics, conditions during labour and delivery, fetal presentation and multiple birth during home visits. We ran log-binomial regression models to estimate the associations between non-cephalic/multiple births and fresh stillbirth, early neonatal mortality and signs of neonatal encephalopathy, respectively, and calculated the per cent attributable fraction. To better understand the context under which these adverse birth outcomes are occurring, we also collected data on maternal awareness of non-cephalic presentation and multiple gestation prior to delivery. Primary outcome measures Risk of experiencing fresh stillbirth, early neonatal encephalopathy and early neonatal mortality associated with non-cephalic and multiple birth, respectively. Results Non-cephalic presentation had a particularly high risk of fresh stillbirth (aRR 12.52 (95% CI 7.86 to 19.95), reference: cephalic presentation). 20.2% of all fresh stillbirths were associated with non-cephalic presentation. For multiple births, there was a fourfold increase in early neonatal mortality (aRR: 4.57 (95% CI 1.44 to 14.50), reference: singleton births). 3.4% of early neonatal mortality was associated with multiple gestation. Conclusions Globally and in Nepal, a large percentage of stillbirths and neonatal mortality is associated with intrapartum-related complications. Despite the low incidence of non-cephalic and multiple birth, a notable proportion of adverse intrapartum-related outcomes is associated with these conditions. As the proportion of neonatal deaths attributable to intrapartum-related complications continues to rise, there is a need to investigate how best to advance diagnostic capacity and management of these conditions. Trial registration number NCT01177111; pre-results

Risk and Burden of Adverse Intrapartum-Related Outcomes Associated with Non-Cephalic and Multiple Birth in Rural Nepal: a Prospective Cohort Study.

OBJECTIVES: Intrapartum-related complications are the second leading cause of neonatal death worldwide. We estimate the community-level risk and burden of intrapartum-related fetal/neonatal mortality and morbidity associated with non-cephalic and multiple birth in rural Sarlahi District, Nepal. DESIGN: Community-based prospective cohort study. SETTING: Rural Sarlahi District, Nepal. PARTICIPANTS: Pregnant women residing in the study area. METHODS: We collected data on maternal background characteristics, conditions during labour and delivery, fetal presentation and multiple birth during home visits. We ran log-binomial regression models to estimate the associations between non-cephalic/multiple births and fresh stillbirth, early neonatal mortality and signs of neonatal encephalopathy, respectively, and calculated the per cent attributable fraction. To better understand the context under which these adverse birth outcomes are occurring, we also collected data on maternal awareness of non-cephalic presentation and multiple gestation prior to delivery. PRIMARY OUTCOME MEASURES: Risk of experiencing fresh stillbirth, early neonatal encephalopathy and early neonatal mortality associated with non-cephalic and multiple birth, respectively. RESULTS: Non-cephalic presentation had a particularly high risk of fresh stillbirth (aRR 12.52 (95% CI 7.86 to 19.95), reference: cephalic presentation). 20.2% of all fresh stillbirths were associated with non-cephalic presentation. For multiple births, there was a fourfold increase in early neonatal mortality (aRR: 4.57 (95% CI 1.44 to 14.50), reference: singleton births). 3.4% of early neonatal mortality was associated with multiple gestation. CONCLUSIONS: Globally and in Nepal, a large percentage of stillbirths and neonatal mortality is associated with intrapartum-related complications. Despite the low incidence of non-cephalic and multiple birth, a notable proportion of adverse intrapartum-related outcomes is associated with these conditions. As the proportion of neonatal deaths attributable to intrapartum-related complications continues to rise, there is a need to investigate how best to advance diagnostic capacity and management of these conditions. TRIAL REGISTRATION NUMBER: NCT01177111; pre-results

Obstetric ultrasound use in low and middle income countries: a narrative review

Abstract Introduction Although growing, evidence on the impact, access, utility, effectiveness, and cost-benefit of obstetric ultrasound in resource-constrained settings is still somewhat limited. Hence, questions around the purpose and the intended benefit as well as potential challenges across various domains must be carefully reviewed prior to implementation and scale-up of obstetric ultrasound technology in low-and middle-income countries (LMICs). Main Body This narrative review discusses these issues for those trying to implement or scale-up ultrasound technology in LMICs. Issues addressed in this review include health personnel capacity, maintenance, cost, overuse and misuse of ultrasound, miscommunication between the providers and patients, patient diagnosis and care management, health outcomes, patient perceptions and concerns about fetal sex determination. Conclusion As cost of obstetric ultrasound becomes more affordable in LMICs, it is essential to assess the benefits, trade-offs and potential drawbacks of large-scale implementation. Additionally, there is a need to more clearly identify the capabilities and the limitations of ultrasound, particularly within the context of limited training of providers, to ensure that the purpose for which an ultrasound is intended is actually feasible. We found evidence of obstetric uses of ultrasound improving patient management. However, there was evidence that ultrasound use is not associated with reducing maternal, perinatal or neonatal mortality. Patients in various studies reported to have both positive and negative perceptions and experiences related to ultrasound and lastly, illegal use of ultrasound for determining fetal sex was raised as a concern

A systematic review of community-to-facility neonatal referral completion rates in Africa and Asia

Background An estimated 2.8 million neonatal deaths occur annually worldwide. The vulnerability of newborns makes the timeliness of seeking and receiving care critical for neonatal survival and prevention of long-term sequelae. To better understand the role active referrals by community health workers play in neonatal careseeking, we synthesize data on referral completion rates for neonates with danger signs predictive of mortality or major morbidity in low- and middle-income countries. Methods A systematic review was conducted in May 2014 of the following databases: Medline-PubMed, Embase, and WHO databases. We also searched grey literature. In addition, an investigator group was established to identify unpublished data on newborn referral and completion rates. Inquiries were made to the network of research groups supported by Save the Children’s Saving Newborn Lives project and other relevant research groups. Results Three Sub-Saharan African and five South Asian studies reported data on community-to-facility referral completion rates. The studies varied on factors such as referral rates, the assessed danger signs, frequency of home visits in the neonatal period, and what was done to facilitate referrals. Neonatal referral completion rates ranged from 34 to 97 %, with the median rate of 74 %. Four studies reported data on the early neonatal period; early neonatal completion rates ranged from 46 to 97 %, with a median of 70 %. The definition of referral completion differed by studies, in aspects such as where the newborns were referred to and what was considered timely completion. Conclusions Existing literature reports a wide range of neonatal referral completion rates in Sub-Saharan Africa and South Asia following active illness surveillance. Interpreting these referral completion rates is challenging due to the great variation in study design and context. Often, what qualifies as referral and/or referral completion is poorly defined, which makes it difficult to aggregate existing data to draw appropriate conclusions that can inform programs. Further research is necessary to continue highlighting ways for programs, governments, and policymakers to best aid families in low-resource settings in protecting their newborns from major health consequences

Validity of home-based sonographic diagnosis of obstetric risk factors by auxiliary nurse midwives in rural Nepal

Background Approximately 2·3 million fetal, neonatal, or maternal deaths occur annually during the intrapartum period or on the day of birth. Several risk factors for intrapartum-related complications require ultrasonography for accurate diagnosis, but sonographic services are scarce in low-resource settings. In this study, we aimed to assess the feasibility of community-based ultrasonography conducted by auxiliary nurse midwives to identify basic obstetric risk factors, in rural Sarlahi District, Nepal. We aimed to assess the validity at which these health workers can detect noncephalic position, multiple gestation, and placenta previa and to explore whether sonographic diagnosis could improve outcomes for women with these high-risk conditions. Methods Three auxiliary nurse midwives (ANM) received two 1-week ultrasound trainings at Tribhuvan University Teaching Hospital in Kath mandu, Nepal. Women at 32 weeks’ or more gestation were enrolled in the study, and received ultrasonography from the ANMs during home visits. ANMs used ultrasonography to identify non-cephalic position, multiple gestation, and placenta previa. Images were saved and later reassessed by gold standard ultrasonographers to determine the validity of the ANM assessment. We also compared adverse outcomes in noncephalic or multiple gestation births from the study group with those in a comparison group of women who did not receive ultrasonography from our study, but the study was not powered to detect a difference. Findings We collected data from 815 women. The kappa statistics for diagnosis of non-cephalic position were 0·92, 0·98, and 0·94, respectively, for the three ANMs against the gold standard. Sensitivity, specificity, positive predictive value, and negative predictive value were between 90% and 100% for all ANMs. For multiple gestation pregnancies (n=6), the ANMs were in perfect agreement with both the gold standard reading and maternal postpartum self-report. Two cases of placenta previa were detected, and the gold standard was in agreement with both. There were 4 adverse outcomes out of 19 women (21%) with non-cephalic or multiple gestation pregnancies in the study group compared with 10 out of 36 (28%) in the comparison group. This difference was not significant (p=0·586). Interpretation Our findings suggest that it is feasible for ANMs to conduct ultrasonography to identify basic obstetric risk factors in low-income settings. The difference in birth outcomes in non-cephalic and multiple births, comparing those antenatally diagnosed by ultrasound and those who were not, was not significant; the sample size was too small to detect a diff erence. Further investigation is warranted to determine whether sonographic diagnosis of selected obstetric factors could contribute to improved care-seeking and health outcomes in low-income settings. Funding Cappsci Data for Life Award, SonoSite Soundcaring Program, National Institutes of Health/National Institute of Child Health and Human Development, Bill & Melinda Gates Foundation

National and regional estimates of term and preterm babies born small for gestational age in 138 low-income and middle-income countries in 2010

Background National estimates for the numbers of babies born small for gestational age and the comorbidity with preterm birth are unavailable. We aimed to estimate the prevalence of term and preterm babies born small for gestational age (term-SGA and preterm-SGA), and the relation to low birthweight (\u3c2500 \u3eg), in 138 countries of low and middle income in 2010. Methods Small for gestational age was defined as lower than the 10th centile for fetal growth from the 1991 US national reference population. Data from 22 birth cohort studies (14 low-income and middle-income countries) and from the WHO Global Survey on Maternal and Perinatal Health (23 countries) were used to model the prevalence of term-SGA births. Prevalence of preterm-SGA infants was calculated from meta-analyses. Findings In 2010, an estimated 32·4 million infants were born small for gestational age in low-income and middle-income countries (27% of livebirths), of whom 10·6 million infants were born at term and low birthweight. The prevalence of term-SGA babies ranged from 5·3% of livebirths in east Asia to 41·5% in south Asia, and the prevalence of preterm-SGA infants ranged from 1·2% in north Africa to 3·0% in southeast Asia. Of 18 million low-birthweight babies, 59% were term-SGA and 41% were preterm-SGA. Two-thirds of small-for-gestational-age infants were born in Asia (17·4 million in south Asia). Preterm-SGA babies totalled 2·8 million births in low-income and middle-income countries. Most small-for-gestational-age infants were born in India, Pakistan, Nigeria, and Bangladesh. Interpretation The burden of small-for-gestational-age births is very high in countries of low and middle income and is concentrated in south Asia. Implementation of effective interventions for babies born too small or too soon is an urgent priority to increase survival and reduce disability, stunting, and non-communicable diseases

Perceptions, careseeking, and experiences pertaining to non-cephalic births in rural Sarlahi District, Nepal: a qualitative study.

BACKGROUND: In low-resource settings, a significant proportion of fetal, neonatal, and maternal deaths can be attributed to intrapartum-related complications. Certain risk factors, such as non-cephalic presentation, have a particularly high risk of complications. This qualitative study describes experiences around non-cephalic births and highlights existing perceptions and care-seeking behavior specific to non-cephalic presentation in rural Sarlahi District, Nepal. METHODS: We conducted in-depth interviews with 34 individuals, including women who recently gave birth to a non-cephalic infant and female decision-makers in their households. We also conducted two focus groups with mothers (have two or more children, with at least one child under age five) and two focus groups with grandmothers in the community. RESULTS: Several women described scenes of obstructed labor and practices like provision of unspecified injections early in labor to assist with the delivery. There were reports of arduous care-seeking processes from primary health centers to tertiary facilities, and mixed quality of care among home birth attendants and facility-based health workers respectively. Very few women were aware of the fetal presentation prior to delivery, and we identified no consistent understanding among participants of the risks of and care strategies for non-cephalic births. Risk perception around non-cephalic presentation varied widely. Some participants were acutely aware of potential dangers, while others had not heard of non-cephalic birth. Many interviewees said that the position in which a pregnant woman sleeps could impact the fetal position. Several participants had either taken or heard of medication intended to rotate the fetus into the correct position. CONCLUSIONS: Our findings suggest the mixed quality of and access to care associated with non-cephalic birth and a lack of consistent understanding of the risk of and care for non-cephalic births in rural Nepal. The high risk of the condition and the recommended tertiary care present a dilemma in low-resource settings; the logistical difficulties and the mixed quality of care make care-seeking and referral decisions complex. While public health stakeholders strive to improve the quality of and access to the formal health system, those players must also be sensitive to the potential negative implications of promoting institutional care-seeking

Prevalence of small-for-gestational age and its mortality risk varies by choice of birth-weight-for-gestation reference population

Background We use data from rural Nepal and South India to compare the prevalence of small-for-gestational-age (SGA) and neonatal mortality risk associated with SGA using different birth-weight-for-gestation reference populations. Methods We identified 46 reference populations in low-, middle-, and high-income countries, of which 26 met the inclusion criteria of being commonly cited and having numeric 10th percentile cut points published. Those reference populations were then applied to populations from two community-based studies to determine SGA prevalence and its relative risk of neonatal mortality. Results The prevalence of SGA ranged from 10.5% to 72.5% in Nepal, and 12.0% to 78.4% in India, depending on the reference population. Females had higher rates of SGA than males using reference populations that were not sex specific. SGA prevalence was lowest when using reference populations from low-income countries. Infants who were both preterm and SGA had much higher mortality risk than those who were term and appropriate-for-gestational-age. Risk ratios for those who are both preterm and SGA ranged from 7.34–17.98 in Nepal and 5.29–11.98 in India, depending on the reference population. Conclusions These results demonstrate the value of a common birth-weight-for-gestation reference population that will facilitate comparisons of SGA prevalence and mortality risk across research studies