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

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study.

OBJECTIVE: To generate a global reference for caesarean section (CS) rates at health facilities. DESIGN: Cross-sectional study. SETTING: Health facilities from 43 countries. POPULATION/SAMPLE: Thirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10,045,875 women giving birth from 43 countries for model testing. METHODS: We hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models. MAIN OUTCOME MEASURES: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. RESULTS: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/). CONCLUSIONS: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS. TWEETABLE ABSTRACT: The C-Model provides a customized benchmark for caesarean section rates in health facilities and systems

Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage: a systematic review

INTRODUCTION: Women with postpartum haemorrhage (PPH) in developing countries often present in critical condition when treatment might be insufficient to save lives. Few studies have shown that application of non-pneumatic anti-shock garment (NASG) could improve maternal survival. METHODS: A systematic review of the literature explored the effect of NASG use compared with standard care for treating PPH. Medline, EMBASE and PubMed were searched. Methodological quality was assessed following the criteria suggested by the Cochrane Effective Practice and Organization of Care Group. Guidelines on Meta-analysis of Observational Studies in Epidemiology were used for reporting the results. Mantel-Haenszel methods for meta-analysis of risk ratios were used. RESULTS: Six out 31 studies met the inclusion criteria; only one cluster randomized controlled trial (c-RCT). Among observational studies, NASG fared better than standard care regarding maternal mortality reduction (Relative Risk (RR) 0.52 (95% Confidence interval (CI) 0.36 to 0.77)). A non-significant reduction of maternal mortality risk was observed in the c-RCT (RR: 0.43 (95% CI: 0.14 to 1.33)). No difference was observed between NASG use and standard care on use of blood products. Severe maternal outcomes were used as proxy for maternal death with similar pattern corroborating the trend towards beneficial effects associated with NASG. CONCLUSION: NASG is a temporizing alternative measure in PPH management that shows a trend to reduce PPH-related deaths and severe morbidities. In settings where delays in PPH management are common, particularly where constraints to offer blood products and definitive treatment exist, use of NASG is an intervention that should be considered as a policy option while the standard conditions for care are being optimized

Are hypertensive disorders in pregnancy associated with congenital malformations in offspring? Evidence from the WHO Multicountry cross sectional survey on maternal and newborn health

BACKGROUND: Annually, around 7.9 million children are born with birth defects and the contribution of congenital malformations to neonatal mortality is generally high. Congenital malformations in children born to mothers with hypertensive disorders during pregnancy has marginally been explored. METHODS: Country incidence of congenital malformations was estimated using data on the 310 401 livebirths of the WHO Multicountry Survey which reported information from 359 facilities across 29 countries. A random-effect logistic regression model was utilized to explore the associations between six broad categories of congenital malformations and the four maternal hypertensive disorders "Chronic Hypertension", "Preeclampsia" and "Eclampsia" and "Chronic hypertension with superimposed preeclampsia". RESULTS: The occupied territories of Palestine presented the highest rates in all groups of malformation except for the "Lip/Cleft/Palate" category. Newborns of women with chronic maternal hypertension were associated with a 3.7 (95 % CI 1.3-10.7), 3.9 (95 % CI 1.7-9.0) and 4.2 (95 % CI 1.5-11.6) times increase in odds of renal, limb and lip/cleft/palate malformations respectively. Chronic hypertension with superimposed preeclampsia was associated with a 4.3 (95 % CI 1.3-14.4), 8.7 (95 % CI 2.5-30.2), 7.1 (95 % CI 2.1-23.5) and 8.2 (95 % CI 2.0-34.3) times increase in odds of neural tube/central nervous system, renal, limb and Lip/Cleft/Palate malformations. CONCLUSIONS: This study shows that chronic hypertension in the maternal period exposes newborns to a significant risk of developing renal, limb and lip/cleft/palate congenital malformations, and the risk is further exacerbate by superimposing eclampsia. Additional research is needed to identify shared pathways of maternal hypertensive disorders and congenital malformations

Mode of delivery and pregnancy outcomes in preterm birth: a secondary analysis of the WHO Global and Multi-country Surveys

Many studies have been conducted to examine whether Caesarean Section (CS) or vaginal birth (VB) was optimal for better maternal and neonatal outcomes in preterm births. However, findings remain unclear. Therefore, this secondary analysis of World Health Organization Global Survey (GS) and Multi-country Survey (MCS) databases was conducted to investigate outcomes of preterm birth by mode of delivery. Our sample were women with singleton neonates (15,471 of 237 facilities from 21 countries in GS; and 15,053 of 239 facilities from 21 countries in MCS) delivered between 22 and <37 weeks of gestation. We assessed association between mode of delivery and pregnancy outcomes in singleton preterm births by multilevel logistic regression adjusted for hierarchical data. The prevalences of women with preterm birth delivered by CS were 31.0% and 36.7% in GS and MCS, respectively. Compared with VB, CS was associated with significantly increased odds of maternal intensive care unit admission, maternal near miss, and neonatal intensive care unit admission but significantly decreased odds of fresh stillbirth, and perinatal death. However, since the information on justification for mode of delivery (MOD) were not available, our results of the potential benefits and harms of CS should be carefully considered when deciding MOD in preterm births

Development of criteria for identifying neonatal near- miss cases: analysis of two WHO multicountry cross- sectional studies

To develop and test markers of neonatal severe morbidity for the identification of neonatal near-miss cases. This is a database analysis of two World Health Organization cross-sectional studies: the Global Survey on Maternal and Perinatal Health (WHOGS) and the Multicountry Survey on Maternal and Newborn Health (WHOMCS). The WHOGS was performed in 373 health facilities in 24 countries (2004-2008). The WHOMCS was conducted in 359 health facilities in 29 countries (2010-2011). Data were collected from hospital records of all women admitted for delivery and their respective neonates. Pragmatic markers (birthweight <1750g, Apgar score at 5minutes <7, and gestational age <33weeks) were developed with WHOGS data and validated with WHOMCS data. The diagnostic accuracy of neonatal characteristics and management markers of severity was determined in the WHOMCS. This analysis included 290610 liveborn neonates from WHOGS and 310436 liveborn neonates from WHOMCS. The diagnostic accuracy of pragmatic and management markers of severity for identifying early neonatal deaths was very high: sensitivity, 92.8% (95% CI 91.8-93.7%); specificity, 92.7% (95% CI 92.6-92.8%); positive likelihood ratio, 12.7 (95% CI 12.5-12.9); negative likelihood ratio, 0.08 (95% CI 0.07-0.09); diagnostic odds ratio, 163.4 (95% CI 141.6-188.4). A positive association was found between the frequency of neonatal near-miss cases and Human Development Index. Newborn infants presenting selected markers of severity and surviving the first neonatal week could be considered as neonatal near-miss cases. This definition and criteria may be seen as a basis for future applications of the near-miss concept in neonatal health. These tools can be used to inform policy makers on how best to apply scarce resources for improving the quality of care and reducing neonatal mortality1211SI11011

Development of criteria for identifying neonatal near- miss cases: analysis of two WHO multicountry cross- sectional studies

ObjectiveTo develop and test markers of neonatal severe morbidity for the identification of neonatal near-miss cases. DesignThis is a database analysis of two World Health Organization cross-sectional studies: the Global Survey on Maternal and Perinatal Health (WHOGS) and the Multicountry Survey on Maternal and Newborn Health (WHOMCS). SettingThe WHOGS was performed in 373 health facilities in 24 countries (2004-2008). The WHOMCS was conducted in 359 health facilities in 29 countries (2010-2011). PopulationData were collected from hospital records of all women admitted for delivery and their respective neonates. MethodsPragmatic markers (birthweight <1750g, Apgar score at 5minutes <7, and gestational age <33weeks) were developed with WHOGS data and validated with WHOMCS data. The diagnostic accuracy of neonatal characteristics and management markers of severity was determined in the WHOMCS. ResultsThis analysis included 290610 liveborn neonates from WHOGS and 310436 liveborn neonates from WHOMCS. The diagnostic accuracy of pragmatic and management markers of severity for identifying early neonatal deaths was very high: sensitivity, 92.8% (95% CI 91.8-93.7%); specificity, 92.7% (95% CI 92.6-92.8%); positive likelihood ratio, 12.7 (95% CI 12.5-12.9); negative likelihood ratio, 0.08 (95% CI 0.07-0.09); diagnostic odds ratio, 163.4 (95% CI 141.6-188.4). A positive association was found between the frequency of neonatal near-miss cases and Human Development Index. ConclusionNewborn infants presenting selected markers of severity and surviving the first neonatal week could be considered as neonatal near-miss cases. This definition and criteria may be seen as a basis for future applications of the near-miss concept in neonatal health. These tools can be used to inform policy makers on how best to apply scarce resources for improving the quality of care and reducing neonatal mortality.1211SI11011

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.

OBJECTIVE:To 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. DESIGN:Secondary analysis of a cross-sectional study. SETTING:Twenty-nine countries from the World Health Organization Multicountry Survey on Maternal and Newborn Health. POPULATION:29,647 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. METHODS:We 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 MEASURES:Severe maternal outcomes, neonatal morbidity, and intra-hospital early neonatal mortality. RESULTS:Odds 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. CONCLUSIONS:Elective 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