Obesity and pregnancy

Universidade Federal de São Paulo (UNIFESP)Universidade Federal de São Paulo (UNIFESP) Departamento de ObstetríciaFaculdade de Medicina do ABCOrganização Mundial da Saúde Departamento de Saúde Reprodutiva e Pesquisa Unidade de Saúde Materna e PerinatalUNIFESP, Depto. de ObstetríciaSciEL

How much time is available for antenatal care consultations? Assessment of the quality of care in rural Tanzania

BACKGROUND: Many women in Sub-Saharan African countries do not receive key recommended interventions during routine antenatal care (ANC) including information on pregnancy, related complications, and importance of skilled delivery attendance. We undertook a process evaluation of a successful cluster randomized trial testing the effectiveness of birth plans in increasing utilization of skilled delivery and postnatal care in Ngorongoro district, rural Tanzania, to document the time spent by health care providers on providing the recommended components of ANC. METHODS: The study was conducted in 16 health units (eight units in each arm of the trial). We observed, timed, and audio-recorded ANC consultations to assess the total time providers spent with each woman and the time spent for the delivery of each component of care. T-test statistics were used to compare the total time and time spent for the various components of ANC in the two arms of the trial. We also identified the topics discussed during the counselling and health education sessions, and examined the quality of the provider-woman interaction. RESULTS: The mean total duration for initial ANC consultations was 40.1 minutes (range 33-47) in the intervention arm versus 19.9 (range 12-32) in the control arm p < 0.0001. Except for drug administration, which was the same in both arms of the trial, the time spent on each component of care was also greater in the intervention health units. Similar trends were observed for subsequent ANC consultations. Birth plans were always discussed in the intervention health units. Counselling on HIV/AIDS was also prioritized, especially in the control health units. Most other recommended topics (e.g. danger signs during pregnancy) were rarely discussed. CONCLUSION: Although the implementation of birth plans in the intervention health units improved provider-women dialogue on skilled delivery attendance, most recommended topics critical to improving maternal and newborn survival were rarely covered

Portrayal of caesarean section in Brazilian women’s magazines: 20 year review

Objective To assess the quality and comprehensiveness of the information on caesarean section provided in Brazilian women’s magazines

Maternal and Perinatal Outcomes of Twin Pregnancy in 23 Low- and Middle-Income Countries

Background: Twin pregnancies in low- and middle-income countries (LMICs) pose a high risk to mothers and newborns due to inherent biological risks and scarcity of health resources. We conducted a secondary analysis of the WHO Global Survey dataset to analyze maternal and perinatal outcomes in twin pregnancies and factors associated with perinatal morbidity and mortality in twins.Methods: We examined maternal and neonatal characteristics in twin deliveries in 23 LMICs and conducted multi-level logistic regression to determine the association between twins and adverse maternal and perinatal outcomes.Results: 279,425 mothers gave birth to 276,187 (98.8%) singletons and 6,476 (1.2%) twins. Odds of severe adverse maternal outcomes (death, blood transfusion, ICU admission or hysterectomy) (AOR 1.85, 95% CI 1.60-2.14) and perinatal mortality (AOR 2.46, 95% CI 1.40-4.35) in twin pregnancies were higher, however early neonatal death (AOR 2.50, 95% CI 0.95-6.62) and stillbirth (AOR 1.22, 95% CI 0.58-2.57) did not reach significance. Amongst twins alone, maternal age 15%, born second, preterm birth and low birthweight were associated with perinatal mortality. Marriage and caesarean section were protective.Conclusions: Twin pregnancy is a significant risk factor for maternal and perinatal morbidity and mortality in low- resource settings; maternal risk and access to safe caesarean section may determine safest mode of delivery in LMICs. Improving obstetric care in twin pregnancies, particularly timely access to safe caesarean section, is required to reduce risk to mother and baby.Australian Postgraduate AwardA & A Saw ScholarshipUniv Western Australia, Sch Populat Hlth, Fac Med Dent & Hlth Sci, Perth, WA 6009, AustraliaUNDP UNFPA UNICEF WHO World Bank Special Programm, Dept Reprod Hlth & Res, World Hlth Org, Geneva, SwitzerlandUniversidade Federal de São Paulo, Dept Obstet, São Paulo, BrazilBrazilian Cochrane Ctr, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Obstet, São Paulo, BrazilWeb of Scienc

Making stillbirths count, making numbers talk - issues in data collection for stillbirths.

BACKGROUND: Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care. DISCUSSION: In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings. SUMMARY: Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems

Do Italian women prefer cesarean section? Results from a survey on mode of delivery preferences

Background: About 20 million cesareans occur each year in the world and rates have steadily increased in almost all middle- and high-income countries over the last decades. Maternal request is often argued as one of the key forces driving this increase. Italy has the highest cesarean rate of Europe, yet there are no national surveys on the views of Italian women about their preferences on route of delivery. This study aimed to assess Italian women's preference for mode of delivery, as well as reasons and factors associated with this preference, in a nationally representative sample of women.Methods: This cross sectional survey was conducted between December 2010-March 2011. An anonymous structured questionnaire asked participants what was their preferred mode of delivery and explored the reasons for this preference by assessing their agreement to a series of statements. Participants were also asked to what extent their preference was influenced by a series of possible sources. the 1st phase of the study was carried out among readers of a popular Italian women's magazine (Io Donna). in a 2nd phase, the study was complemented by a structured telephone interview.Results: A total of 1000 Italian women participated in the survey and 80% declared they would prefer to deliver vaginally if they could opt. the preference for vaginal delivery was significantly higher among older (84.7%), more educated (87.6%), multiparous women (82.3%) and especially among those without any previous cesareans (94.2%). the main reasons for preferring a vaginal delivery were not wanting to be separated from the baby during the first hours of life, a shorter hospital stay and a faster postpartum recovery. the main reasons for preferring a cesarean were fear of pain, convenience to schedule the delivery and because it was perceived as being less traumatic for the baby. the source which most influenced the preference of these Italian women was their obstetrician, followed by friends or relatives.Conclusion: Four in five Italian women would prefer to deliver vaginally if they could opt. Factors associated with a higher preference for cesarean delivery were youth, nulliparity, lower education and a previous cesarean.Universidade Federal de São Paulo, Dept Obstet, São Paulo, BrazilWHO, Dept Reprod Hlth & Res, CH-1211 Geneva, SwitzerlandOsservatorio Nazl Salute Donna, ONDa, Milan, ItalyInst Clin Effectiveness & Hlth Policy, Buenos Aires, DF, ArgentinaUniv Florence, Meyer Children Hosp, I-50121 Florence, ItalyUniversidade Federal de São Paulo, Dept Obstet, São Paulo, BrazilWeb of Scienc

Implementation of evidence-based antenatal care in Mozambique: a cluster randomized controlled trial: study protocol

Background: Antenatal care (ANC) reduces maternal and perinatal morbidity and mortality directly through the detection and treatment of pregnancy-related illnesses, and indirectly through the detection of women at increased risk of delivery complications. The potential benefits of quality antenatal care services are most significant in low-resource countries where morbidity and mortality levels among women of reproductive age and neonates are higher. WHO developed an ANC model that recommended the delivery of services scientifically proven to improve maternal, perinatal and neonatal outcomes. The aim of this study is to determine the effect of an intervention designed to increase the use of the package of evidence-based services included in the WHO ANC model in Mozambique. The primary hypothesis is that the intervention will increase the use of evidence-based practices during ANC visits in comparison to the standard dissemination channels currently used in the country. Methods: This is a demonstration project to be developed through a facility-based cluster randomized controlled trial with a stepped wedge design. The intervention was tailored, based on formative research findings, to be readily applicable to local prenatal care services and acceptable to local pregnant women and health providers. The intervention includes four components: the provision of kits with all necessary medicines and laboratory supplies for ANC (medical and non-medical equipment), a storage system, a tracking system, and training sessions for health care providers. Ten clinics were selected and will start receiving the intervention in a random order. Outcomes will be computed at each time point when a new clinic starts the intervention. The primary outcomes are the delivery of selected healthcare practices to women attending the first ANC visit, and secondary outcomes are the delivery of selected healthcare practices to women attending second and higher ANC visits as well as the attitude of midwives in relation to adopting the practices. This demonstration project is pragmatic in orientation and will be conducted under routine conditions. Discussion: There is an urgent need for effective and sustainable scaling-up approaches of health interventions in low-resource countries. This can only be accomplished by the engagement of the country’s health stakeholders at all levels. This project aims to achieve improvement in the quality of antenatal care in Mozambique through the implementation of a multifaceted intervention on three levels: policy, organizational and health care delivery levels. The implementation of the trial will probably require a change in accountability and behaviour of health care providers and we expect this change in ‘habits’ will contribute to obtaining reliable health indicators, not only related to research issues, but also to health care outcomes derived from the new health care model. At policy level, the results of this study may suggest a need for revision of the supply chain management system. Given that supply chain management is a major challenge for many low-resource countries, we envisage that important lessons on how to improve the supply chain in Mozambique and other similar settings, will be drawn from this study

Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trial

Background: High levels of maternal and newborn mortality and morbidity remain a daunting reality in many lowincome countries. Several interventions delivered during antenatal care have been shown to improve maternal and newborn outcomes, but stockouts of medical supplies at point of care can prevent implementation of these services. We aimed to evaluate whether a supply chain strategy based on the provision of kits could improve quality of care. Methods: We did a pragmatic, stepped-wedge, cluster-randomised controlled trial at ten antenatal care clinics in Mozambique. Clinics were eligible if they were not already implementing the proposed antenatal care package; they served at least 200 new pregnant women per year; they had Maternal and Child Health (MCH) nurses; and they were willing to participate. All women attending antenatal care visits at the participating clinics were included in the trial. Participating clinics were randomly assigned to shift from control to intervention on prespecified start dates. The intervention involved four components (kits with medical supplies, a cupboard to store these supplies, a tracking sheet to monitor stocks, and a one-day training session). The primary outcomes were the proportion of women screened for anaemia and proteinuria, and the proportion of women who received mebendazole in the first antenatal care visit. The intervention was delivered under routine care conditions, and analyses were done according to the intention-to-treat principle. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201306000550192. Findings: Between March, 2014, and January, 2016, 218 277 antenatal care visits were registered, with 68 598 first and 149679 follow-up visits. We found significant improvements in all three primary outcomes. In first visits, 5519 (14·6%) of 37 826 women were screened for anaemia in the control period, compared with 30 057 (97·7%) of 30772 in the intervention period (adjusted odds ratio 832·40; 99% CI 666·81–1039·11; p\u3c0·0001); 3739 (9·9%) of 37 826 women were screened for proteinuria in the control period, compared with 29874 (97·1%) of 30772 in the intervention period (1875·18; 1447·56–2429·11; p\u3c0·0001); and 17 926 (51·4%) of 34 842 received mebendazole in the control period, compared with 24 960 (88·2%) of 28 294 in the intervention period (1·88; 1·70–2·09; p\u3c0·0001). The effect was immediate and sustained over time, with negligible heterogeneity between sites. Interpretation: A supply chain strategy that resolves stockouts at point of care can result in a vast improvement in quality during antenatal care visits, when compared with the routine national process for procurement and distribution of supplies. Funding: Government of Flanders and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproductio

Antimicrobial resistance, biofilm synthesis and virulence genes in Salmonella isolated from pigs bred on intensive farms

Salmonella is the second cause of foodborne infection in humans in the USA and Europe. Pigs represent the second most important reservoir for the pathogen and the consumption of pork meat is a major risk factor for human salmonellosis. Here, we evaluated the virulence patterns of eleven Salmonella isolated from pigs (carcasses and faces) bred in intensive farms in the north of Italy. The two serotypes identified were S. Typhimurium and its monophasic variant 1,4,5,12:i:-. None of the isolates was an ESBL producer, as confirmed also by PCR. However, the presence of a multidrug resistant pattern was evident, with all the isolates being resistant to at least to five antimicrobial agents belonging to various classes. Moreover, six out of eleven isolates showed important resistance profiles, such as resistance against colistin and ciprofloxacin, with nine to twelve recorded resistances. The isolates were negative for the biofilm synthesis test, while four different virulotypes were characterized. All the isolates showed the presence of invA, hilA, stn, ssrA, sipC. One sample also harbored ssaR and spvC genes. One strain was positive for all the virulence genes tested and was resistant to 12 antimicrobial agents. The present study contributes new data to the surveillance program for antibiotic resistance. Furthermore, the presence of eleven highly virulent isolates poses concern for human health in relation to their diffusion in the environment