Commentary: reducing the world's stillbirths

One of the major success stories of modern obstetrics in high-income countries in the last 5 decades is the reduction of stillbirths from rates as high as 50 per 1000 births to about 5 per 1000 births today. Fetal mortality associated with obstructed labour, asphyxia, hypertension, diabetes, Rh disease, placental abruption, post-term pregnancies and infections such as syphilis all have declined. Much of this success has occurred in term births in the intrapartum period so that most stillbirths in high-income countries now occur in the antepartum period and are pre-term. Current stillbirth rates in many low- and middle-income countries, and especially in those areas within the countries with poorly functioning health systems, approximate those seen in high-income countries 50 years ago. A major difference between the stillbirths occurring in high-income countries and those occurring elsewhere is the preponderance of late pre-term, term and intrapartum stillbirths in low-resource countries. Those stillbirths should be relatively easy to prevent by known risk assessment methods and prompt delivery, often by Cesarean section. This commentary addresses an extensive six-paper review of stillbirths with an emphasis on low- and middle-income countries. Among the conclusions are that while a number of interventions have been shown to be effective in reducing stillbirths, unless there is a functioning health system in which these interventions can be implemented, the potential for a sustainable and substantial reduction in stillbirth rates will not be reached

Translating research evidence into practice: a report from the 2nd International Conference on Maternal and Newborn Health from KLE University - Belagavi, India

The Jawaharlal Nehru Medical College (JNMC) Women’s and Children’s Health Research Unit (WCHRU) of the Karnataka Lingayat Education (KLE) Academy of Higher Education and Research Deemed-to-be-University and its collaborators convened the ‘2nd International Conference on Maternal and Newborn Health -Translating Research Evidence to Practice’ to address the common theme of improving maternal and newborn health in low- and middle- income countries (LMIC). This supplement, including 16 manuscripts, reflects much of the research presented at the conference, including analyses of the state of knowledge, as well as completed, ongoing and planned research in these areas conducted by the WCHRU in India together with many collaborators across high-income and LMIC. The first paper reviews maternal, fetal and neonatal mortality in low-income countries, considers their causes, as well as evidence for potential interventions to reduce mortality. A second paper addresses near miss maternal mortality. Several manuscripts address the research conducted by WCHRU and their colleagues in a multi-center research network. One study examines rates of miscarriage and medically terminated pregnancy in India and the risk factors for these occurrences. Another paper addresses stillbirth and its risk factors, both in India as well as in other LMIC. Haemorrhage and preeclampsia/eclampsia, important causes of maternal mortality, stillbirth and neonatal morbidity in LMIC, are addressed in a series of papers summarizing trials of interventions to reduce improve outcomes associated with these conditions. Poor maternal and infant nutritional status, which contribute to adverse outcomes, are addressed through papers which describe a number of important studies that the WCHRU and their colleagues have conducted to attempt to improve nutritional status. Another paper describes a study to investigate causes of stillbirth and deaths among preterm births, which will utilize new techniques to investigate the infectious causes of these deaths. Finally, the supplement addresses the process for dissemination of research results to inform public policy. Together these manuscripts represent a body of research to inform interventions to reduce maternal, fetal and newborn mortality and illustrates what a dedicated research group together with institutional support can accomplish

Improving pregnancy outcomes in low- and middle-income countries

This paper reviews the very large discrepancies in pregnancy outcomes between high, low and middle-income countries and then presents the medical causes of maternal mortality, stillbirth and neonatal mortality in low-and middle-income countries. Next, we explore the medical interventions that were associated with the very rapid and very large declines in maternal, fetal and neonatal mortality rates in the last eight decades in high-income countries. The medical interventions likely to achieve similar declines in pregnancy-related mortality in low-income countries are considered. Finally, the quality of providers and the data to be collected necessary to achieve these reductions are discussed. It is emphasized that single interventions are unlikely to achieve important reductions in pregnancy-related mortality. Instead, improving the overall quality of pregnancy-related care across the health-care system will be necessary. The conditions that cause maternal mortality also cause stillbirths and neonatal deaths. Focusing on all three mortalities together is likely to have a larger impact than focusing on one of the mortalities alone

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

Maternal, fetal and neonatal mortality: lessons learned from historical changes in high income countries and their potential application to low-income countries

Background There are large differences in pregnancy outcome between high income countries and many middle and low income countries. In fact, maternal, fetal and neonatal mortality rates in many low-income countries approximate those that were seen in high-income countries nearly a century ago. Findings This paper documents the very substantial reductions in maternal, fetal and neonatal mortality rates in high income countries over the last century and explores the likely reasons for those reductions. The conditions responsible for the current high mortality rates in low and middle income countries are discussed as are the interventions likely to result in substantial reductions in maternal, fetal and neonatal mortality from those conditions. The conditions that result in maternal mortality are often responsible for fetal and neonatal mortality and the interventions that save maternal lives often reduce fetal and neonatal mortality as well. Single interventions rarely achieve substantial reductions in mortality. Instead, upgrading the system of care so that appropriate interventions could be applied at appropriate times is most likely to achieve the desired reductions in maternal, fetal and neonatal mortality

Infection and stillbirth

Infection may cause stillbirth by several mechanisms, including direct infection, placental damage, and severe maternal illness. Various organisms have been associated with stillbirth, including many bacteria, viruses, and protozoa. In developed countries, between 10% and 25% of stillbirths may be caused by an infection, whereas in developing countries, which have much higher stillbirth rates, the contribution of infection is much greater. In developed countries, ascending bacterial infection, both before and after membrane rupture, with organisms such as Escherichia coli, group B streptococci, and Ureaplasma urealyticum is usually the most common infectious cause of stillbirth. However, in areas where syphilis is prevalent, up to half of all stillbirths may be caused by this infection alone. Malaria may be an important cause of stillbirth in women infected for the first time in pregnancy. The two most important viral causes of stillbirth are parvovirus and Coxsackie virus, although a number of other viral infections appear to be causal. Toxoplasma gondii, leptospirosis, Listeria monocytogenes, and the organisms that cause leptospirosis, Q fever, and Lyme disease have all been implicated as etiologic for stillbirth. In certain developing countries, the stillbirth rate is high and the infection-related component so great that achieving a substantial reduction in stillbirth should be possible by reducing maternal infections. However, because infection-related stillbirth is uncommon in developed countries, and because those that do occur are caused by a wide variety of organisms, reducing this etiologic component of stillbirth much further will be difficult

Prevalence of anxiety, depression and associated factors among pregnant women of Hyderabad, Pakistan.

Background: Few studies have examined the relationship between antenatal depression, anxiety and domestic violence in pregnant women in developing countries, despite the World Health Organization\u27s estimates that depressive disorders will be the second leading cause of the global disease burden by 2020. There is a paucity of research on mood disorders, their predictors and sequelae among pregnant women in Pakistan. Aims: To determine the prevalence of anxiety and depression and evaluate associated factors, including domestic violence, among pregnant women in an urban community in Pakistan. Methods: All pregnant women living in identified areas of Hyderabad, Pakistan were screened by government health workers for an observational study on maternal characteristics and pregnancy outcomes. Of these, 1,368 (76%) of eligible women were administered the validated Aga Khan University Anxiety Depression Scale at 20-26 weeks of gestation. Results: Eighteen per cent of the women were anxious and/or depressed. Psychological distress was associated with husband unemployment (p = 0.032), lower household wealth (p = 0.027), having 10 or more years of formal education ( p = 0.002), a first (p = 0.002) and an unwanted pregnancy ( p \u3c 0.001). The strongest factors associated with depression/anxiety were physical/sexual and verbal abuse, 42% of women who were physically and/or sexually abused and 23% of those with verbal abuse had depression/anxiety compared to 8% of those who were not abused. Conclusions: Anxiety and depression commonly occur during pregnancy in Pakistani women, rates are highest in women experiencing sexual/physical as well as verbal abuse, but they are also increased among women with unemployed spouses and those with lower household wealth. These results suggest that developing a screening and treatment programme for domestic violence and depression/anxiety during pregnancy may improve the mental health status of pregnant Pakistani women

Infectious Causes of Stillbirth: A Clinical Perspective

Untreated infection may cause stillbirth by several mechanisms, including direct fetal infection, placental damage, and severe maternal illness. Many bacteria, viruses, and protozoa have been associated with stillbirth. In developed countries, up to 24% of stillbirths have been attributed to infection, although with increased availability of sophisticated diagnostics and rigorous screening, it appears likely that higher numbers may actually be associated with infection. In developed countries, ascending bacterial infection is usually the most common infectious cause of stillbirth, with a number of viral infections also an important factor. Screening, prevention and treatment of maternal infections are important to reduce stillbirth risk

Pregnancy Outcomes among Women with an Unintended Pregnancy: Findings from a Prospective Registry in Rural Pakistan

Background: Unintended pregnancies are an important public health issue in both developed and developing countries. An unintended pregnancy may affect maternal health seeking behavior during the antenatal and postpartum periods, which can adversely affect perinatal outcomes. Aim: The specific aim of our study was to measure antepartum, intrapartum, and postpartum pregnancy outcomes among women with unintended pregnancies in a rural Pakistani population.Methods: Using a prospective maternal and newborn health registry in Thatta Pakistan, we evaluated temporal associations between unintended pregnancy and several dimensions of health seeking behavior including: antenatal care, preference for private versus government facility for antenatal care, and use of tetanus toxoid (TT) vaccine during the current pregnancy. We performed logistic regressions to analyze the data.Results: In a multivariable model, we found that women who claimed their pregnancies as unintended were 1.27 times more likely to not utilize any facility for antenatal care as compared to women with intended pregnancies [OR = 1.27; 95% CI (1.11 - 1.46)]. Likewise, women with unintended pregnancies were 1.23 times more likely to not receive tetanus toxoid vaccine during the antenatal period [OR = 1.23; 95% CI (1.06 - 1.41)] and were 1.20 times more likely to utilize a government facility compared to private facilities for the antenatal care as compared to their counterparts with intended pregnancies [OR = 1.20; 95% CI (1.04 - 1.38)].Conclusions: Women with unintended pregnancies were less likely to seek antenatal care and preferred government facilities when they did enroll; these facilities are known for providing subsidized but suboptimal care. Our results show that women who decide to carry unintended pregnancies should be considered a high-risk group that requires focused counseling on adherence to antenatal care and delivery planning. Prevention of unintended and unplanned pregnancies in rural areas through provision of family planning services should be encouraged

Ursinus College Alumni Journal, May 1951

President\u27s page • Lloyd H. Wood, \u2725, inaugurated as Pennsylvania\u27s Lt. Governor • Dr. H. A. Cochran, of Temple, to address graduating class • Ursinus to be honored by Newcomen Society • Russian DP starts new life at Ursinus • Artist to glorify queen in May Day pageant • Catalogue re-designed • Program completed for 1951 Alumni Day • Dinner held for seniors • Scholarship fund benefit proceeds total $1700 • Marjorie Trayes becomes Rutger\u27s Dean on July 1 • Crossley first reported casualty from Ursinus • Rhea D. Johnson retires • Laucks antique collection near museum proportions • Mack Trucks, Inc., head sets great 1950 record • First Ursinus faculty, courses are selected • Sports review: New candidates display promise as varsity nine posts 3-6 record; Undefeated in 3 years, Helfferich takes MAC award; Slim holdover track squad greets Gurzynski; Alumnae continue active in Philadelphia area sports; Court team winds up successful season with 10 wins in 18 games; Dr. Miller selected as new Ursinus tennis coach; Mermaids drop seven, veteran \u2752 squad sure; Top sports record goes to girls\u27 basketball team; Ursinus\u27 1910 team and the same players today • Obituary • News about ourselveshttps://digitalcommons.ursinus.edu/alumnijournal/1041/thumbnail.jp