Stillbirth rates in 20 countries of Latin America: an ecological study

Objective: To describe country-level stillbirth rates and their change over time in Latin America, and to measure the association of stillbirth rates with socio-economic and health coverage indicators in the region. Design: Ecological study. Setting: 20 countries of Latin America. Population or Sample: Aggregated data from pregnant women with countries as units of analysis. Methods: We used stillbirth estimates, and socio-economic and healthcare coverage indicators reported from 2006 to 2016 from UNICEF, United Nations Development Programme and World Bank datasets. We calculated Spearman's correlation coefficients between stillbirths rates and socioeconomic and health coverage indicators. Main outcome measures: National estimates of stillbirth rates in each country. Results: The estimated stillbirth rate for Latin America for 2015 was 8.1 per 1000 births (range 3.1–24.9). Seven Latin America countries had rates higher than 10 stillbirths per 1000 births. The average annual reduction rate for the region was 2% (range 0.1–3.8%), with the majority of Latin America countries ranging between 1.5 and 2.5%. National stillbirth rates were correlated to: women's schooling (rS = −0.7910), gross domestic product per capita (rS = −0.8226), fertility rate (rS = 0.6055), urban population (rS = −0.6316), and deliveries at health facilities (rS = −0.6454). Conclusions: Country-level estimated stillbirth rates in Latin America varied widely in 2015. The trend and magnitude of reduction in stillbirth rates between 2000 and 2015 was similar to the world average. Socio-economic and health coverage indicators were correlated to stillbirth rates in Latin America. Tweetable abstract: Stillbirth rates decreased in Latin America but remain relatively high, with wide variations among countries.Fil: Pingray, María Verónica. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Althabe, Fernando. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Vazquez, Paula. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Correa, Malena. Instituto de Efectividad Clínica y Sanitaria; Argentina. University of Tulane; Estados UnidosFil: Pajuelo, Mónica. University Johns Hopkins; Estados UnidosFil: Belizan, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentin

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

The increasing trend in preterm birth in public hospitals in northern Argentina

Objective: To identify factors associated with the increasing incidence of preterm birth in northern Argentina. Methods: In an observational study, data were reviewed from a prospective, population-based registry of pregnancy outcomes in six cities in 2009-2012. The primary outcome was preterm birth (at 20-37 weeks). Bivariate tests and generalized estimating equations were used within a conceptual hierarchical framework to estimate the cluster-corrected annual trend in odds of preterm birth. Results: The study reviewed data from 11 433 live births. There were 484 (4.2%) preterm births. The incidence of preterm births increased by 38% between 2009 and 2012, from 37.5 to 51.7 per 1000 live births. Unadjusted risk factors for preterm birth included young or advanced maternal age, normal body mass index, nulliparity, no prenatal care, no vitamins or supplements during pregnancy, multiple gestation, and maternal hypertension or prepartum hemorrhage. The prevalence of many risk factors increased over the study period, but variations in these factors explained less than 1% of the increasing trend in preterm birth. Conclusion: The incidence of preterm births insix small cities in northern Argentina increased greatly between 2009 and 2012. This trend was unexplained by the risk factors measured. Other factors should be assessed in future studies.Fil: Weaver, Emily H.. University of North Carolina School at Chapel Hill; Estados UnidosFil: Gibbons, Luz. 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. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentin

Stillbirth rates in 20 countries of Latin America: an ecological study

Objective: To describe country-level stillbirth rates and their change over time in Latin America, and to measure the association of stillbirth rates with socio-economic and health coverage indicators in the region. Design: Ecological study. Setting: 20 countries of Latin America. Population or Sample: Aggregated data from pregnant women with countries as units of analysis. Methods: We used stillbirth estimates, and socio-economic and healthcare coverage indicators reported from 2006 to 2016 from UNICEF, United Nations Development Programme and World Bank datasets. We calculated Spearman's correlation coefficients between stillbirths rates and socioeconomic and health coverage indicators. Main outcome measures: National estimates of stillbirth rates in each country. Results: The estimated stillbirth rate for Latin America for 2015 was 8.1 per 1000 births (range 3.1–24.9). Seven Latin America countries had rates higher than 10 stillbirths per 1000 births. The average annual reduction rate for the region was 2% (range 0.1–3.8%), with the majority of Latin America countries ranging between 1.5 and 2.5%. National stillbirth rates were correlated to: women's schooling (rS = −0.7910), gross domestic product per capita (rS = −0.8226), fertility rate (rS = 0.6055), urban population (rS = −0.6316), and deliveries at health facilities (rS = −0.6454). Conclusions: Country-level estimated stillbirth rates in Latin America varied widely in 2015. The trend and magnitude of reduction in stillbirth rates between 2000 and 2015 was similar to the world average. Socio-economic and health coverage indicators were correlated to stillbirth rates in Latin America. Tweetable abstract: Stillbirth rates decreased in Latin America but remain relatively high, with wide variations among countries.Fil: Pingray, María Verónica. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Althabe, Fernando. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Vazquez, Paula. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Correa, Malena. Instituto de Efectividad Clínica y Sanitaria; Argentina. University of Tulane; Estados UnidosFil: Pajuelo, Mónica. University Johns Hopkins; Estados UnidosFil: Belizan, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; 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

The Need of a Neonatal Preparation for Chagas Disease

Fil: Sosa-Estani, Sergio. ANLIS Dr.C.G.Malbrán. Centro Nacional de Diagnóstico e Investigación en Endemo-Epidemias; Argentina.Fil: Belizan, Jose M. Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires; Argentina.Fil: Althabe, Fernando. Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires; Argentina.Fil: Rubinstein, Aldofo. Institute for Clinical Effectiveness and Health Policy, Buenos Aires; Argentina.We have read about the efforts and initiatives related to the design of drugs for parasitic diseases in McKerrow's article [1] with interest and expectation. One of the pressing needs in this area is for a neonatal preparation for Chagas disease. Satisfactory achievements have been made in Argentina in relation to the transmission of the disease by vectors and through blood transfusion [2,3]. Vertical transmission is now the great challenge in eradicating Chagas disease. Around 800–1,300 neonates infected with Trypanosmoma cruzi are born every year in our country [4]. Almost 99% of all births occur in hospital, thus allowing the detection of infants born with parasites immediately after birth. The initiation of treatment of these neonates before they and their mothers leave the hospital is a good strategy to obtain high treatment coverage. The later attendance of mothers with their children to health-care facilities is quite unpredictable and irregular. Also, it is difficult to link information about maternal and neonatal parasitic status obtained at birth with later attendance at other health-care facilities

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

Treatment selection in multi-arm multi-stage designs: With application to a postpartum haemorrhage trial

Background: Multi-arm multi-stage trials are an efficient, adaptive approach for testing many treatments simultaneously within one protocol. In settings where numbers of patients available to be entered into trials and resources might be limited, such as primary postpartum haemorrhage, it may be necessary to select a pre-specified subset of arms at interim stages even if they are all showing some promise against the control arm. This will put a limit on the maximum number of patients required and reduce the associated costs. Motivated by the World Health Organization Refractory HaEmorrhage Devices trial in postpartum haemorrhage, we explored the properties of such a selection design in a randomised phase III setting and compared it with other alternatives. The objectives are: (1) to investigate how the timing of treatment selection affects the operating characteristics; (2) to explore the use of an information-rich (continuous) intermediate outcome to select the best-performing arm, out of four treatment arms, compared with using the primary (binary) outcome for selection at the interim stage; and (3) to identify factors that can affect the efficiency of the design. / Methods: We conducted simulations based on the refractory haemorrhage devices multi-arm multi-stage selection trial to investigate the impact of the timing of treatment selection and applying an adaptive allocation ratio on the probability of correct selection, overall power and familywise type I error rate. Simulations were also conducted to explore how other design parameters will affect both the maximum sample size and trial timelines. / Results: The results indicate that the overall power of the trial is bounded by the probability of ‘correct’ selection at the selection stage. The results showed that good operating characteristics are achieved if the treatment selection is conducted at around 17% of information time. Our results also showed that although randomising more patients to research arms before selection will increase the probability of selecting correctly, this will not increase the overall efficiency of the (selection) design compared with the fixed allocation ratio of 1:1 to all arms throughout. / Conclusions: Multi-arm multi-stage selection designs are efficient and flexible with desirable operating characteristics. We give guidance on many aspects of these designs including selecting the intermediate outcome measure, the timing of treatment selection, and choosing the operating characteristics

Constructing a Population-Based Research Database from Routine Maternal Screening Records: A Resource for Studying Alloimmunization in Pregnant Women

Although screening for maternal red blood cell antibodies during pregnancy is a standard procedure, the prevalence and clinical consequences of non-anti-D immunization are poorly understood. The objective was to create a national database of maternal antibody screening results that can be linked with population health registers to create a research resource for investigating these issues.Each birth in the Swedish Medical Birth Register was uniquely identified and linked to the text stored in routine maternal antibody screening records in the time window from 9 months prior to 2 weeks after the delivery date. These text records were subjected to a computerized search for specific antibodies using regular expressions. To illustrate the research potential of the resulting database, selected antibody prevalence rates are presented as tables and figures, and the complete data (from more than 60 specific antibodies) presented as online moving graphical displays.More than one million (1,191,761) births with valid screening information from 1982–2002 constitute the study population. Computerized coverage of screening increased steadily over time and varied by region as electronic records were adopted. To ensure data quality, we restricted analysis to birth records in areas and years with a sustained coverage of at least 80%, representing 920,903 births from 572,626 mothers in 17 of the 24 counties in Sweden. During the study period, non-anti-D and anti-D antibodies occurred in 76.8/10,000 and 14.1/10,000 pregnancies respectively, with marked differences between specific antibodies over time.This work demonstrates the feasibility of creating a nationally representative research database from the routine maternal antibody screening records from an extended calendar period. By linkage with population registers of maternal and child health, such data are a valuable resource for addressing important clinical questions, such as the etiological significance of non-anti-D antibodies