Preterm birth, an unresolved issue

Premature birth is the world's leading cause of neonatal mortality with worldwide estimates indicating 11.1% of all live births were preterm in 2010. Preterm birth rates are increasing in most countries with continual differences in survival rates amongst rich and poor countries. Preterm birth is currently an important unresolved global issue with research efforts focusing on uterine quiescence and activation, the 'omics' approaches and implementation science in order to reduce the incidence and increase survival rates of preterm babies. The journal Reproductive Health has published a supplement entitled Born Too Soon which addresses factors in the preconception and pregnancy period which may increase the risk of preterm birth and also outlines potential interventions which may reduce preterm birth rates and improve survival of preterm babies by as much as 84% annually. This is critical in order to achieve the Millennium Development Goal (MDG 4) for child survival by 2015 and beyond.Fil: Belizan, Jose. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Hofmeyr, Justus. University of The Witwatersrand;Fil: Buekens, Pierre. University of Tulane; Estados UnidosFil: Salaria, Natasha. BioMed Central; Reino Unid

Frequency of the Congenital Transmission of Trypanosoma cruzi: A Systematic Review and Meta-Analysis

BACKGROUND: Chagas disease is caused by the parasite Trypanosoma cruzi and is endemic in much of Latin America. With increased globalisation and immigration, it is a risk in any country, partly through congenital transmission. The frequency of congenital transmission is unclear. OBJECTIVE: To assess the frequency of congenital transmission of T. cruzi. SEARCH STRATEGY: PubMed, Journals@Ovid Full Text, EMBASE, CINAHL, Fuente Academica and BIREME databases were searched using seven search terms related to Chagas disease or T. cruzi and congenital transmission. SELECTION CRITERIA: The inclusion criteria were the following: Dutch, English, French, Portuguese or Spanish language; case report, case series or observational study; original data on congenital T. cruzi infection in humans; congenital infection rate reported or it could be derived. This systematic review included 13 case reports/series and 51 observational studies. DATA COLLECTION AND ANALYSIS: Two investigators independently collected data on study characteristics, diagnosis and congenital infection rate. The principal summary measure - the congenital transmission rate - is defined as the number of congenitally infected infants divided by the number of infants born to infected mothers. A random effects model was used. MAIN RESULTS: The pooled congenital transmission rate was 4.7% (95% confidence interval: 3.9-5.6%). Countries where T. cruzi is endemic had a higher rate of congenital transmission compared with countries where it is not endemic (5.0% versus 2.7%). CONCLUSIONS: Congenital transmission of Chagas disease is a global problem. Overall risk of congenital infection in infants born to infected mothers is about 5%. The congenital mode of transmission requires targeted screening to prevent future cases of Chagas disease.Fil: Howard, Elizabeth J.. University of Tulane; Estados UnidosFil: Xiong, Xu. University of Tulane; Estados UnidosFil: Carlier, Yves. Université Libre de Bruxelles; BélgicaFil: Sosa-estani, Sergio Alejandro. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud. Instituto Nacional de Parasitología; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Buekens, Pierre. University of Tulane; Estados Unido

Reducing neonatal mortality associated with preterm birth: gaps in knowledge of the impact of antenatal corticosteroids on preterm birth outcomes in low-middle income countries

The Global Network’s Antenatal Corticosteroids Trial (ACT), was a multi-country, cluster-randomized trial to improve appropriate use of antenatal corticosteroids (ACS) in low-resource settings in low-middle income countries (LMIC). ACT substantially increased ACS use in the intervention clusters, but the intervention failed to show benefit in the targeted < 5th percentile birth weight infants and was associated with increased neonatal mortality and stillbirth in the overall population. In this issue are six papers which are secondary analyses related to ACT that explore potential reasons for the increase in adverse outcomes overall, as well as site differences in outcomes. The African sites appeared to have increased neonatal mortality in the intervention clusters while the Guatemalan site had a significant reduction in neonatal mortality, perhaps related to a combination of ACS and improving obstetric care in the intervention clusters. Maternal and neonatal infections were increased in the intervention clusters across all sites and increased infections are a possible partial explanation for the increase in neonatal mortality and stillbirth in the intervention clusters, especially in the African sites. The analyses presented here provide guidance for future ACS trials in LMIC. These include having accurate gestational age dating of study subjects and having care givers who can diagnose conditions leading to preterm birth and predict which women likely will deliver in the next 7 days. All study subjects should be followed through delivery and the neonatal period, regardless of when they deliver. Clearly defined measures of maternal and neonatal infection should be utilized. Trials in low income country facilities including clinics and those without newborn intensive care seem to be of the highest priority.Fil: McClure, Elizabeth M.. RTI International; Estados UnidosFil: Goldenberg, Robert L.. Columbia University; Estados UnidosFil: Jobe, Alan H.. Cincinnati Children’s Hospital; Estados UnidosFil: Miodovnik, Menachem. Eunice Kennedy Shriver National Institute of Child and Human Development; Estados UnidosFil: Koso Thomas, Marion. Eunice Kennedy Shriver National Institute of Child and Human Development; Estados UnidosFil: Buekens, Pierre. University of Tulane; Estados UnidosFil: Belizan, Jose. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Althabe, Fernando. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Lost opportunities for effective management of obstetric conditions to reduce maternal mortality and severe maternal morbidity in Argentina and Uruguay

Objective: To review the use of evidence-based practices in the care of mothers who died or had severe morbidity attending public hospitals in two Latin American countries. Methods: This study is part of a multicenter intervention to increase the use of evidence-based obstetric practice. Data on maternal deaths and women admitted to intensive care units whose deliveries occurred in 24 hospitals in Argentina and Uruguay were analyzed. Primary outcomes were use rates of effective interventions to reduce maternal mortality (MM) and severe maternal morbidity (SMM). Results: A total of 106 women were included: 26 maternal deaths and 80 women with SMM. Some effective interventions for severe acute hemorrhage had a high use rate, such as blood transfusion (91%) and timely cesarean delivery (75%), while active management of the third stage of labor (25%) showed a lower rate. The overall use rate of effective interventions was 58% (95% CI, 49%-67%). This implies that 42% of the women did not receive one of the effective interventions to reduce MM and SMM. Conclusion: This study shows a low use of effective interventions to reduce MM and SMM in public hospitals in Argentina and Uruguay. Dissemination and implementation of evidence-based practices must be guaranteed to effectively achieve progress on maternal health.Fil: Karolinski, Ariel Pedro. Gobierno de la Ciudad Autónoma de Buenos Aires. Hospital General de Agudos Carlos Durand; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Mazzoni, Agustina. Gobierno de la Ciudad Autónoma de Buenos Aires. Hospital General de Agudos Carlos Durand; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Belizan, Jose. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Althabe, Fernando. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Bergel, Eduardo. Organizacion Mundial de la Salud; ArgentinaFil: Buekens, Pierre. University of Tulane; Estados Unido

Zika virus infection in pregnant women in Honduras: study protocol

Background: Although there is increasing evidence for a relationship between symptomatic Zika virus (ZIKV) maternal infection, and microcephaly, a firm causal relation has yet to be established by epidemiologic studies. Studies also need to be conducted in recently infected settings. Our objectives are to assess the frequency of ZIKV infection during pregnancy in Honduras and the association of microcephaly with ZIKV infection. Methods/Design: We will perform a prospective study enrolling pregnant women at their first antenatal visit and following them up until delivery. At the time of enrollment, women will be interviewed to collect socio-demographic data, data needed to locate them for potential additional follow-up, and data about ZIKV symptoms during pregnancy. We will also collect maternal blood as soon as possible after enrollment. A probable maternal ZIKV infection will be defined as positive for maternal ZIKV IgM. A confirmed maternal ZIKV infection will be defined as positive for ZIKV IgM confirmed by plaque reduction neutralization test. Microcephaly at birth will be defined as an occipito-frontal circumference <2SD for sex and gestational age. Our objective is to enroll 2000 pregnant women. In a first step, we will follow a case cohort design and only analyze blood samples for cases and a sub-cohort of 200 women randomly selected. Blood samples for the entire population will be analyzed at a later stage if funds are available. Discussion: This protocol was designed to be implemented with minimal resources. It allows a cohort to be built, which could be a foundation for future in-depth and follow-up studies.Fil: Buekens, Pierre. University of Tulane; Estados UnidosFil: Alger, Jackeline. Universidad Nacional Autónoma de Honduras; HondurasFil: Althabe, Fernando. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Bergel, Eduardo. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Berrueta, Amanda Mabel. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Bustillo, Carolina. Hospital Escuela. Departamento de Ginecología y Obstetricia; HondurasFil: Cafferata, Maria Luisa. Hospital de Clínicas. Unidad de Investigación Clínica y Epidemiológica Montevideo; UruguayFil: Harville, Emily. University of Tulane; Estados UnidosFil: Rosales, Karla. Región Sanitaria Metropolitana Distrito Central de Francisco Morazán; HondurasFil: Wesson, Dawn M.. University of Tulane; Estados UnidosFil: Zuniga, Concepcion. Hospital Escuela Universitario. Instituto de Enfermedades Infecciosas y Parasitología Antonio Vidal; Hondura

Sources of influence on pregnant women's preferred mode of delivery in Buenos Aires, Argentina

Background: Understanding influences on women's preferred delivery mode is vital for planning interventions to reduce cesarean rates and for ensuring that women receive correct information. Our objectives were to: determine if sources of information influencing a pregnant woman's preferred delivery mode and knowledge of cesarean indications differ by sociodemographic characteristics; to conduct a factor analysis of items related to information sources influencing this preference; and to determine if knowledge differs by information sources influencing this preference or their underlying latent constructs. Methods: Data from a prospective cohort study conducted in Buenos Aires was analyzed. Healthy nulliparous women aged 18-35, at >32 weeks of gestation and with live, singleton pregnancies participated. The primary research questions were evaluated using Chi-square tests, factor analysis, logistic regression, and generalized estimating equations. Results: A total of 382 women participated in the study. Women of lower socioeconomic status were more influenced by people, magazines and TV/movies in their mode of delivery preferences, and had poorer knowledge of cesarean indications. Sources of influence for preferred delivery mode and factors derived in factor analysis were not associated with knowledge level when considered individually or together, or when adjusted for sociodemographic characteristics, or when accounting for clustering by the hospital sector (public or private). Conclusions: Higher socioeconomic status is associated with being less influenced by people and with better knowledge of indications for cesarean delivery. Knowledge of cesarean indications was not associated with the source of information about mode of delivery preferences.Fil: Amyx, Melissa Michele. University of Tulane; Estados UnidosFil: Gibbons, Luz. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Pque. Centenario. Centro de Investigaciones En Epidemiología y Salud Publica. Instituto de Efectividad Clinica y Sanitaria. Centro de Investigaciones En Epidemiología y Salud Publica.; ArgentinaFil: Xiong, Xu. University of Tulane; Estados UnidosFil: Mazzoni, Agustina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Pque. Centenario. Centro de Investigaciones En Epidemiología y Salud Publica. Instituto de Efectividad Clinica y Sanitaria. Centro de Investigaciones En Epidemiología y Salud Publica.; ArgentinaFil: Althabe, Fernando. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Pque. Centenario. Centro de Investigaciones En Epidemiología y Salud Publica. Instituto de Efectividad Clinica y Sanitaria. Centro de Investigaciones En Epidemiología y Salud Publica.; ArgentinaFil: Buekens, Pierre. University of Tulane; Estados UnidosFil: Belizan, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Pque. Centenario. Centro de Investigaciones En Epidemiología y Salud Publica. Instituto de Efectividad Clinica y Sanitaria. Centro de Investigaciones En Epidemiología y Salud Publica.; Argentin

A cluster randomized controlled trial of a behavioral intervention to facilitate the development and implementation of clinical practice guidelines in Latin American maternity hospitals: the Guidelines Trial: Study protocol [ISRCTN82417627]

BACKGROUND: A significant proportion of the health care administered to women in Latin American maternity hospitals during labor and delivery has been demonstrated to be ineffective or harmful, whereas effective interventions remain underutilized. The routine use of episiotomies and the failure to use active management of the third stage of labor are good examples. METHODS/DESIGN: The aim of this trial is to evaluate the effect of a multifaceted behavioral intervention on the use of two evidence-based birth practices, the selective use of episiotomies and active management of the third stage of labor (injection of 10 International Units of oxytocin). The intervention is based on behavioral and organizational change theories and was based on formative research. Twenty-four hospitals in three urban districts of Argentina and Uruguay will be randomized. Opinion leaders in the 12 intervention hospitals will be identified and trained to develop and implement evidence-based guidelines. They will then disseminate the guidelines using a multifaceted approach including academic detailing, reminders, and feedback on utilization rates. The 12 hospitals in the control group will continue with their standard in-service training activities. The main outcomes to be assessed are the rates of episiotomy and oxytocin use during the third stage of labor. Secondary outcomes will be perineal sutures, postpartum hemorrhages, and birth attendants' opinions

Factors associated with HIV and syphilis screenings among pregnant women at first antenatal visit in Lusaka, Zambia

Objectives: To identify characteristics associated with obtaining HIV and syphilis screenings of pregnant women attending a first antenatal visit in Lusaka, Zambia. Results: Among 18,231 participants from April 2015 to January 2016, 95% obtained HIV screening, 29% obtained syphilis screening, and 4% did not obtain antenatal HIV or syphilis screenings. Divorced/separated women were associated with a moderate decrease in prevalence of obtaining HIV (adjusted prevalence ratio (aPR) 0.88, 95% confidence interval (95% CI) 0.82, 0.95) and syphilis (aPR 0.51, 95% CI 0.27, 0.96) screenings compared to married women. Women with previous pregnancies were associated with a slight decrease in prevalence of obtaining HIV screening (aPR 0.97, 95% CI 0.95, 0.99) compared to women without previous pregnancy. Older women ≥ 35 years were associated with a slight decrease in prevalence of obtaining HIV screening (aPR 0.96, 95% CI 0.92, 0.99) compared to younger women. The statistically significant differences were not of clinical relevance as defined by a proportional difference of 10 percent. Findings of this study show that a vast majority of pregnant women are obtaining HIV screenings but not syphilis screenings during first antenatal visit. Provision of antenatal HIV and syphilis screening at first visit is only weakly related to patient level factors.Fil: Davis, Rindcy. University of Tulane; Estados UnidosFil: Xiong, Xu. University of Tulane; Estados UnidosFil: Althabe, Fernando. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Lefante, John. University of Tulane; Estados UnidosFil: Cafferata, Maria Luisa. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Mwenechanya, Musaku. University Teaching Hospital Lusaka; ZambiaFil: Mwanakalanga, Friday Habulembe. University Teaching Hospital Lusaka; ZambiaFil: Chomba, Elwyn. University Teaching Hospital Lusaka; ZambiaFil: Buekens, Pierre. University of Tulane; Estados Unido

Geographic Variations in Test Reactivity for the Serological Diagnosis of Trypanosoma cruzi Infection

Chagas disease is a neglected disease caused by Trypanosoma cruzi parasites. Most diagnosis is based on serological tests, but the lack of a gold standard test complicates the measurement of test performance. To overcome this limitation, we used samples from a cohort of well-characterized T. cruzi-infected women to evaluate the reactivity of two rapid diagnostic tests and one enzyme-linked immunosorbent assay (ELISA). Our cohort was derived from a previous study on congenital transmission of T. cruzi and consisted of 481 blood/plasma samples from Argentina (n = 149), Honduras (n = 228), and Mexico (n = 104), with at least one positive T. cruzi PCR. Reactivity of the three tests ranged from 70.5% for the Wiener ELISA to 81.0% for the T-Detect and 90.4% for the Stat-Pak rapid tests. Test reactivity varied significantly among countries and was highest in Argentina and lowest in Mexico. When considering at least two reactive serological tests to confirm seropositivity, over 12% of T. cruzi infection cases from Argentina were missed by serological tests, over 21% in Honduras, and an alarming 72% in Mexico. Differences in test performance among countries were not due to differences in parasitemia, but differences in antibody levels against ELISA antigens were observed. Geographic differences in T. cruzi parasite strains as well as genetic differences among human populations both may contribute to the discrepancies in serological testing. Improvements in serological diagnostics for T. cruzi infections are critically needed to ensure an optimum identification of cases.Fil: Truyens, Carine. Université Libre de Bruxelles; BélgicaFil: Dumonteil, Eric. University of Tulane; Estados UnidosFil: Alger, Jackeline. Universidad Nacional Autónoma de Honduras; HondurasFil: Cafferata, Maria Luisa. No especifíca;Fil: Ciganda, Alvaro. No especifíca;Fil: Gibbons, Luz. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Herrera, Claudia. University of Tulane; Estados UnidosFil: Sosa-Estani, Sergio Alejandro. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Buekens, Pierre. University of Tulane; Estados Unido

Smoking Patterns and Receipt of Cessation Services Among Pregnant Women in Argentina and Uruguay

Introduction: The 5A’s (Ask, Advise, Assess, Assist, and Arrange) strategy, a best-practice approach for cessation counseling, has been widely implemented in high-income countries for pregnant women; however, no studies have evaluated implementation in middle-income countries. The study objectives were to assess smoking patterns and receipt of 5A’s among pregnant women in Buenos Aires, Argentina and Montevideo, Uruguay. Methods: Data were collected through administered questionnaires to women at delivery hospitalizations during October 2011–May 2012. Eligible women attended one of 12 maternity hospitals or 21 associated prenatal care clinics. The questionnaire included demographic data, tobacco use/cessation behaviors, and receipt of the 5A’s. Self-reported cessation was verified with saliva cotinine. Results: Overall, of 3400 pregnant women, 32.8% smoked at the beginning of pregnancy; 11.9% quit upon learning they were pregnant or later during pregnancy, and 20.9% smoked throughout pregnancy. Smoking prevalence varied by country with 16.1% and 26.7% who smoked throughout pregnancy in Argentina and Uruguay, respectively. Among pregnant smokers in Argentina, 23.8% reported that a provider asked them about smoking at more than one prenatal care visit; 18.5% were advised to quit; 5.3% were assessed for readiness to quit, 4.7% were provided assistance, and 0.7% reported follow-up was arranged. In Uruguay, those percentages were 36.3%, 27.9%, 5.4%, 5.6%, and 0.2%, respectively. Conclusions: Approximately, one in six pregnant women smoked throughout pregnancy in Buenos Aires and one in four in Montevideo. However, a low percentage of smokers received any cessation assistance in both countries. Healthcare providers are not fully implementing the recommended 5A’s intervention to help pregnant women quit smoking.Fil: Berrueta, Amanda Mabel. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Morello, Paola. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Alemán, Alicia. Unidad de Investigación Clínica y Epidemiológica Montevideo; UruguayFil: Tong, Van T.. Centers for Disease Control and Prevention; Estados UnidosFil: Johnson, Carolyn. Tulane School of Public Health and Tropical Medicine; Estados UnidosFil: Dietz, Patricia M.. Centers for Disease Control and Prevention; Estados UnidosFil: Farr, Sherry L.. Centers for Disease Control and Prevention; Estados UnidosFil: Mazzoni, Agustina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Colomar, Mercedes. Unidad de Investigación Clínica y Epidemiológica Montevideo; UruguayFil: Ciganda, Alvaro. Unidad de Investigación Clínica y Epidemiológica Montevideo; UruguayFil: Llambi, Laura. Unidad de Investigación Clínica y Epidemiológica Montevideo; UruguayFil: Becú, Ana. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Gibbons, Luz. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Smith, Ruben A.. Centers for Disease Control and Prevention; Estados UnidosFil: Buekens, Pierre. Tulane School of Public Health and Tropical Medicine; Estados UnidosFil: Belizan, Jose. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Althabe, Fernando. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin