Newborn resuscitation: defining best practice for low-income settings

Current resuscitation practices are often poor in low-income settings. The purpose of this review was to summarise recent evidence, relevant to developing countries, on best practice in the provision of newborn resuscitation. Potential studies for inclusion were identified using structured searches of MEDLINE via PubMed. Two reviewers independently evaluated retrieved studies for inclusion. The methodological quality of the selected articles was assessed using the Oxford Centre for Evidence-Based Medicine (CEBM) levels of evidence, whilst the Scottish Intercollegiate Guidelines Network (SIGN) grading system was used for subsequent recommendations. Based on available evidence, where there is meconium-stained liquor, routine perineal suction of all babies and endotracheal suction of active babies do not prevent meconium aspiration syndrome and have potential risks. Adequate ventilation is possible with a bag-valve-mask device and room air is just as efficient as oxygen for initial resuscitation. This review supports the view that effective resuscitation is possible with basic equipment and minimal skills. Thus, where resources are limited, it should be possible to improve neonatal outcomes through promotion of the effective use of a bag-valve-mask alone, without access to more sophisticated and expensive technologies. Basic, effective resuscitation should therefore be available at all health facilities and potentially in the community.

The history of preconception care: evolving guidelines and standards

This article explores the history of the preconception movement in the United States and the current status of professional practice guidelines and standards. Professionals with varying backgrounds (nurses, nurse practitioners, family practice physicians, pediatricians, nurse midwives, obstetricians/gynecologists) are in a position to provide preconception health services; standards and guidelines for numerous professional organizations, therefore, are explored. The professional nursing organization with the most highly developed preconception health standards is the American Academy of Nurse Midwives (ACNM); for physicians, it is the American College of Obstetricians and Gynecologists (ACOG). These guidelines and standards are discussed in detail.

[Early results of evidence-based perinatal care technologies implemented by Zestafoni maternity hospital]

The implementation of evidence-based effective perinatal care in Georgia is very limited. This study was planned as descriptive to define the results of implementation of effective perinatal care technologies, to compare them with existed obstetric practices and reliable research summaries. We identified procedures which should be avoided as routine and practices that should be encouraged. The rate of existed practices was defined retrospectively through analyses of hospital records and interview with health care providers participating in labor and delivery process. The results of implementation of effective perinatal care technologies were determined by exit interviews with postpartum women, verified using hospital notes. The four practices widely used in obstetric care where evidence suggests that they should be avoided as routine, decreased after implementation of effective perinatal care technologies: use of pubic shaving dropped from 97% to 6%, enema from 98% to 5%, episiotomy from 82% to 21%, and lithotomic position from 100% to 30%. Social support or companionship during labor and delivery has been encouraged and used routinely. Obstetric practice must follow best available evidence. There is a need to implement widely effective perinatal care technologies and develop evidence-based clinical practice guidelines which will ensure progressive changes in clinical practice.

Intrapartum Electronic Fetal Heart Rate Monitoring and the Prevention of Perinatal Brain Injury

OBJECTIVE

Electronic fetal heart rate monitoring (EFM) is the most widely used method of intrapartum surveillance, and our objective is to review its ability to prevent perinatal brain injury and death.

DATA SOURCES

Studies that quantified intrapartum EFM and its relation to specific neurologic outcomes (seizures, periventricular leukomalacia, cerebral palsy, death) were eligible for inclusion. MEDLINE was searched from 1966 to 2006 for studies that examined the relationship between intrapartum EFM and perinatal brain injury using these MeSH and text words: "cardiotocography," "electronic fetal monitoring," "intrapartum fetal heart rate monitoring," "intrapartum fetal monitoring," and "fetal heart rate monitoring."

METHODS OF STUDY SELECTION

This search strategy identified 1,628 articles, and 41 were selected for further review. Articles were excluded for the following reasons: in case reports, letters, commentaries, and review articles, intrapartum EFM was not quantified, or specific perinatal neurologic morbidity was not measured. Three observational studies and a 2001 meta-analysis of 13 randomized controlled trials were selected for determination of the effect of intrapartum EFM on perinatal brain injury.

TABULATION, INTEGRATION, AND RESULTS

Electronic fetal monitoring was introduced into widespread clinical practice in the late 1960s based on retrospective studies comparing its use to historical controls where auscultation was performed in a nonstandardized manner. Case-control studies have shown correlation of EFM abnormalities with umbilical artery base excess, but EFM was not able to identify cerebral white matter injury or cerebral palsy. Of 13 randomized controlled trials, one showed a significant decrease in perinatal mortality with EFM compared with auscultation. Meta-analysis of the randomized controlled trials comparing EFM with auscultation have found an increased incidence of cesarean delivery and decreased neonatal seizures but no effect on the incidence of cerebral palsy or perinatal death.

CONCLUSION

Although intrapartum EFM abnormalities correlate with umbilical cord base excess and its use is associated with decreased neonatal seizures, it has no effect on perinatal mortality or pediatric neurologic morbidity.

Substance abuse in pregnancy: opioid substitution in a northern Ireland maternity unit

An increase in illicit drug use in Northern Ireland may well have links to the resolution of political conflict, which started in the mid 1990s. Social issues, heretofore hidden, have emerged into the limelight and may be worsened by paramilitary involvement. Registered addicts in the four Health Board areas have shown an increase from 1997 with the greatest number resident within the Northern Board Area. As the prevalence of heroin use in Northern Ireland increased, the Department of Health and Social Services and Public Safety (DHSSPS) commissioned a report, to recommend the development of substitute prescribing services. A case series of pregnancies was reviewed, within the Northern Board Area, where the mother was taking opioid substitution therapy. This resulted in baseline data of outcome for both mother and baby specific to a Northern Ireland population. The different medications for opioid substitution are also assessed. This information will guide a co-ordinated approach that involves obstetrician, anaesthetist, psychiatrist, midwife and social worker to the care of these high-risk pregnancies. Eighteen pregnancies were identified in the study period. Sixteen of these had viable outcomes. One was a twin pregnancy. Outcome data was therefore available for 17 infants. Information was obtained regarding patients' social and demographic background, drug taking behaviour and substitution regimen. Antenatal and intrapartum care was assessed and infants were followed up to the time of hospital discharge.

Are breastfeeding rates higher among mothers delivering in Baby Friendly accredited maternity units in the UK?

BACKGROUND

The promotion and support of breastfeeding is a global priority with benefits for maternal and infant health, particularly in low-income and middle-income countries where its relevance for child survival is undisputed. However, breastfeeding rates are strikingly low in some higher-income countries, including the UK. Evidence to support the effectiveness of public health interventions to increase rates of breastfeeding initiation and duration in this setting is limited. We examined whether mothers were more likely to start and continue to breastfeed if they delivered in a UNICEF UK Baby Friendly accredited maternity unit, in a cohort with a high representation of disadvantaged and lower socioeconomic groups with traditionally low rates of breastfeeding.

METHODS

We analysed maternally reported breastfeeding initiation and prevalence of any breastfeeding at 1 month for 17 359 singleton infants according to maternity unit Baby Friendly Initiative participation status at birth (accredited, certificated, or neither award).

RESULTS

Mothers delivering in accredited maternity units were more likely to start breastfeeding than those delivering in units with neither award [adjusted rate ratio: 1.10, 95% confidence interval (CI) 1.05-1.15], but were not more likely to breastfeed at 1 month (0.96, 95% CI 0.84-1.09), after adjustment for social, demographic, and obstetric factors. Antenatal class attendance (1.14, 95% CI 1.11-1.17), vaginal delivery (1.05, 1.03-1.08), a companion at delivery (1.09, 1.04-1.16), and maternal post-partum hospital stay >24 h (1.06, 1.04-1.09) were also independently associated with breastfeeding initiation.

CONCLUSIONS

Policies to increase the proportion of maternity units participating in the UNICEF UK Baby Friendly Initiative are likely to increase breastfeeding initiation but not duration. Other strategies are required in order to support UK mothers to breastfeed for the recommended duration.

Obstetric outcome in post-term pregnancies: time for reappraisal in clinical management

BACKGROUND

The objective of this study was to determine the outcome of pregnancy in post-term cases compared with term cases in a well defined population receiving modern obstetric care.

METHODS

We utilized the population-based birth registry data of the Kuopio University Hospital (1990-2000) to investigate pregnancy outcome in 1,678 post-term singleton pregnancies. The general obstetric population (n=22,712) was used as a reference group in logistic regression analysis.

RESULTS

The overall frequency of post-term pregnancies was 6.9% and the incidence of post-term pregnancies was found to be increased in obese, primiparous, and smoking women, whereas in women with chronic diseases and obstetric risks deliveries were induced earlier. The risks of macrosomia, maternal complications, and operative deliveries were increased in post-term pregnancies. Post-term infants experienced meconium passage (21.2% versus 12.8%) (p<0.01) and intrapartum asphyxia (3.4% versus 2.1%) (p<0.01) significantly more often than the controls. However, the stillbirth rate was low, probably due to careful monitoring of these pregnancies.

CONCLUSIONS

Although high-risk pregnancies were not allowed to come post-term, postmaturity per se is a moderate risk state compromising fetal well-being with regard to meconium passage and acid-base status at birth. We conclude that simple antenatal monitoring beyond 42 weeks reduces perinatal mortality but is inefficient in reducing meconium-stained liquor seen with increasing gestation.

Effectiveness of a regional self-study perinatal education programme: a successful adaptation in Yucatan, Mexico

OBJECTIVE

To evaluate the effectiveness of the Perinatal Continuing Education Programme (PCEP) in a Latin American country.

METHODS

We carried out a study within secondary and tertiary care, and rural Mexican Institute of Social Security (IMSS) hospitals on the Yucatan Peninsula. Participants were doctors, nurses and nursing assistants working with pregnant women and newborns at each hospital. The PCEP was translated into Spanish and then implemented between January 1998 and December 2001. Two nurses at each hospital were trained to co-ordinate the programme and the personnel were invited to participate. Participation involved purchasing the self-teaching books, study outside work hours and participation in skills demonstration and practice sessions. Evaluation included the percentage of personnel who participated in and those who completed the programme, an opinion survey of the programme, level of pre- and post-intervention knowledge, and the quality of neonatal care according to expert-recommended routines. Results were analysed with chi-square and Student's t-tests.

RESULTS

A total of 65.3% of the 1421 people in the study population began the programme and 72% of those completed it. Improvement was observed in 14 of 23 (P<0.05) evaluated neonatal care practices. Participants rated the written material as very clear and useful in daily practice.

CONCLUSIONS

The PCEP is an effective strategy for improving the level of knowledge and perinatal care in all regional hospitals on the Yucatan Peninsula, Mexico. This initial application of the PCEP in a Spanish-speaking country was successful.

Community-based antenatal and perinatal interventions and newborn survival

BACKGROUND

As part of the millennium development goal (MDG) 4 to reduce by two-thirds the mortality rate among children under five, neonatal mortality rate (NMR) needs to be reduced by half. This is a selective review of the literature of the morbidity and mortality patterns among newborns as well as cost-effective interventions and community aspects of newborn care.

METHODS

Documented causes of morbidity and mortality among newborns were examined in the overall context of developing and developed countries. Cost-effective interventions that have been proven to be inexpensive with evidence or potential to save newborns' lives by international agencies concerned with health, journals and other publications were reviewed. Community aspects of newborn care and what is required at the individual, household and community levels to reduce neonatal morbidity and mortality were also reviewed.

RESULTS

A score of recent publications by the World Health Organization (WHO), Save-the-Children, United Nations Children's Fund (UNICEF), journals, and other scientific publications reported consistently that neonatal mortality constitute 40-70% of deaths in infancy and that 99% of these deaths occurred in developing countries, with highest neonatal mortality rates (NMRs) in sub-Saharan Africa. The global burden of newborn illness shows that a disparity of up to 30-folds exists between countries with highest and lowest NMRs. Four million babies die in developing countries and about 42% of these deaths are due to infections. Other major causes include perinatal asphyxia (21%), birth injuries (11%), prematurity and low birth weight (10%) and congenital abnormalities (11%). It was also observed that two-thirds of the deaths in the neonatal period occur in the first week; among these deaths, two-thirds occurred within the first 24 hours. Review findings also revealed that an integrated, proven and cost-effective intervention such as the mother-baby packages incorporated into a functional and sustainable healthcare delivery system and improved household practices will save newborns' lives. Reports showed that to achieve meaningful development, neonatal mortality will need to be reduced in developing countries.

CONCLUSION

Programmes that are necessary for the reduction in neonatal morbidity and mortality rates are for countries to employ rational mix of quality clinical services, effective public health measures and inexpensive community-based interventions in public and private sectors and to scale-up known cost-effective interventions.

[Short interpregnancy intervals: risk factors and perinatal outcomes]

OBJECTIVES

To study risk factors and perinatal outcomes in short interpregnancy intervals.

MATERIALS AND METHODS

Retrospective study, between 1995 and 2001, comparing women with short interpregnancy intervals (<6 months, n = 192) and women controls (interpregnancy intervals between 18 and 23 months, n = 210). The analysis included demographical and social factors, maternal medical histories and perinatal outcomes for the 2(nd) pregnancy.

RESULTS

Risk factors of short interpregnancy intervals were: young age, no anterior contraception, celibacy, medical history of intrauterine fetal death or medical pregnancy termination and high parity and gestity. The patients at risks of short interpregnancy intervals often belong to little supported social background, are generally without profession and often leave against medical opinion. The short interval between pregnancies is associated to a high score of prematurity (19% vs 8%, OR = 2.8, p < 0.001).

CONCLUSION

These data suggest that obstetricians and other care providers need to be alert to these identifiable risk factors and then direct preventive strategies during and after pregnancy.

Compliance with a risk factor-based intrapartum prophylaxis program for neonatal group B streptococcal disease

AIM

The US Centre for Disease Control (CDC) recently amended their guidelines for the prevention of early-onset group B streptococcal disease (EOGBSD) of the newborn to recommend bacteriological screening, rather than risk factor-based screening, as the preferred method of identifying 'at risk' mother-infant pairs. This recommendation was derived from population data suggesting that the effectiveness of bacteriological screening was superior to a risk-factor approach because antibiotic compliance was better with the former. Whether poor compliance and therefore impaired prevention is inherent in risk-factor screening has not been widely tested.

METHODS

For a 6-month period we audited compliance with an established risk-factor EOGBSD prophylaxis program.

RESULTS

During the audit period, 1243 women delivered, of whom 287 (23%) had at least one risk factor. Of these women, 193 (67%), representing 15% of all women giving birth, received antibiotics. Thus, there were 94 women who were eligible for antibiotics but did not receive prophylaxis. There were sound clinical reasons for withholding antibiotics in 68 of these. Therefore, the corrected compliance rate within our program was 73%.

CONCLUSION

This compares favourably with published compliance rates with bacteriological-based programs, but we have suggested mechanisms to improve compliance further.

Mozambican midwives' views on barriers to quality perinatal care

Our purpose in this study was to explore the midwives' perception of factors obstructing or facilitating their ability to provide quality perinatal care at a central labor ward in Maputo. In-depth interviews were undertaken with 16 midwives and were analyzed according to grounded theory technique. Barriers to provision of quality perinatal care were identified as follows: (i) the unsupportive environment, (ii) nonempowering and limited interaction with women in labor, (iii) a sense of professional inadequacy and inferiority, and (iv) nonappliance of best caring practices. A model based on the midwives' reflections on barriers to quality perinatal care and responses to these were developed. Actions aimed at overcoming the barriers were improvising and identifying areas in need of change. Identified evading actions were holding others accountable and yielding to dysfunction and structural control. In order to improve perinatal care, the midwives need to see themselves as change agents and not as victims of external and internal causal relationships over which they have no influence. It is moreover essential that the midwives chose actions aiming at overcoming barriers to quality perinatal care instead of choosing evading actions, which might jeopardize the health of the unborn and newborn infant. We suggest that local as well as national education programs need to correspond with existing reality, even if they provide knowledge that surpasses the present possibilities in practice. Quality of intrapartum and the immediate newborn care requires a supportive environment, however, which in the context of this study presented such serious obstacles that they need to be addressed on the national level. Structural and administrative changes are difficult to target as these depend on national organization of maternal health care (MHC) services and national health expenditures.

Cochrane reviews in pregnancy: the role of perinatal randomized trials and systematic reviews in establishing evidence

Evidence from randomized trials and systematic reviews provides the highest level of evidence from which to make clinical decisions. There are over 340 Cochrane reviews and protocols in pregnancy and childbirth; these provide the best single source of evidence for care of pregnant women and their babies, and highlight further research priorities. The challenges to health professionals are to ensure that the Cochrane reviews are prepared, kept up to date, and used in clinical care, and where relevant reliable evidence is not available to ensure that high-quality randomized trials are promptly conducted.

Impacts of participating in confidential enquiry panels: a qualitative study

OBJECTIVE

To describe the impacts of participating in confidential enquiry panels for the Confidential Enquiry into Stillbirths and Deaths in Infancy.

DESIGN

Qualitative interview study.

SETTING

The former northern health region of England.

SAMPLE

Eighteen health professionals who had participated in at least one confidential enquiry panel.

METHODS

Semistructured one-to-one interviews using purposive sampling; transcripts were analysed by identifying recurring themes. Data were organised and coded using NUD*IST.

MAIN OUTCOME MEASURES

Views on the impacts of participation on clinical practice and views on the strengths and limitations of confidential enquiries.

RESULTS

Participants valued attendance at panels as a learning experience that provoked reflection on their own clinical practice. Participants felt that taking part had a positive impact on their clinical thinking and practice by increasing their awareness of standards of care. These impacts occurred through both the detailed examination of cases and the interaction with colleagues from different disciplines and hospitals. Learning impacts were cascaded to colleagues through informal discussion and teaching. Concrete examples of changes in practice at the organisational level, stimulated by panel attendance, were reported.

CONCLUSIONS

The confidential enquiry approach was supported not only as an effective way of assessing care but also as a valuable learning experience that motivated change in clinical practice. Local benefits of nationally coordinated confidential enquiries should be valued and supported in their future development. Wide multidisciplinary participation in enquiry panels coordinated through regional clinical networks should be promoted.

The challenge of improving perinatal care in settings with limited resources. Observations of midwifery practices in Mozambique

The aim of this study was to observe and analyse midwifery care routines related to asphyxia and hypothermia during the perinatal period and to investigate the effect of an in-service education program. A direct non-participant pre- and post-intervention observation study of midwifery a performance during childbirth was conducted at a labour ward in Maputo. The observed groups consisted of 702 and 616 midwifery-attended deliveries. Examination was also conducted of the partographs (702 vs. 616). The quality of midwifery care related to prevention and early detection of asphyxia and hypothermia was found to be inadequate and the intervention had no significant effect upon the midwives' performances. This could be attributed to the quality of the intervention itself or to failure of implementing managerial decisions such as transfer of partograph documentation from obstetricians to midwives. Change in professional performance does not automatically follow awareness of evidence-based midwifery practices, but requires behavioural change, which may be more difficult to achieve.

Best practices for intrapartum care in Zimbabwean health facilities

Evidence-based interventions to ensure a good outcome during childbirth are widely available. Their applicability in various settings depends on local conditions and the resources available. Best practices during normal labour and delivery are described for Zimbabwean health facilities. Practices that have proved value are encouraged and those without benefit are discouraged.

Avaliação da peregrinação anteparto numa amostra de puérperas no Município do Rio de Janeiro, Brasil, 1999/2001

Neste estudo foi avaliada a dificuldade de acesso às maternidades do Município do Rio de Janeiro, Brasil. O objetivo do estudo foi identificar os fatores sociais, demográficos e obstétricos associados à peregrinação anteparto. Para tal foram avaliadas 6.652 puérperas que utilizaram os serviços do SUS por ocasião do parto. Foi observado que 1/3 das pacientes busca assistência em mais de um hospital, não sendo raro pacientes peregrinarem por três ou mais unidades. Vale ressaltar que apenas 1/5 dessas mulheres é transferida de ambulância. Os fatores associados a essa peregrinação foram: área programática de residência, peso ao nascer, idade, cor de pele, estado civil e residência em local onde não há coleta de lixo. Não foi encontrada associação de peregrinação anteparto com escolaridade, índice de Kotelchuck modificado, risco obstétrico na internação, fonte de abastecimento de água e residência em favela.

[Perinatal mortality in the Netherlands: everyone's problem and yet no one's problem]

In 1986, this journal published a paper showing that the rate of decline of perinatal mortality in the Netherlands was lower than in several other European countries. As a result, the Netherlands had lost its position as a country with one of the lowest perinatal mortality rates in the world. Since then, relatively little has happened to redress the situation, despite the fact that several studies have shown that the higher perinatal mortality rates are not due to registration artefacts, and that the quality of perinatal care in the Netherlands is lower than that in countries with lower perinatal mortality rates. In a recent analysis by the Rijksinstituut voor Volksgezondheid en Milieu (State Institute for Public Health and the Environment) it was estimated that between 20 and 25% of the difference between the perinatal mortality rates of the Netherlands and those of Sweden and Finland is due to the higher frequency in the Netherlands of five factors: multiple pregnancies (probably as a result of in-vitro fertilisation), smoking during pregnancy, pregnancies among non-western immigrants, no screening for congenital disorders, and (other) 'substandard' factors in perinatal care. Unfortunately, there are still no signs of a determined policy response. It seems that twenty years of working on the basis of the voluntary participation of many different organisations, and without clear leadership, have not produced the gain in perinatal mortality that would theoretically have been possible.

Perinatal audit in low- and high-income countries

Audit is a term used to include case reviews, criterion-based clinical audit, enquiries into maternal mortality and perinatal deaths, and near-miss reviews. The audit cycle consists of identifying cases, collecting information, analysing the results, formulating recommendations, implementing change and re-evaluating practice, and this cycle must be repeated regularly. Implicit in the process are standards against which practice is measured. These standards are becoming increasingly explicit and may be based on hospital protocols or regional or national guidelines. When protocols or guidelines are drawn up, this must be on the basis of multidisciplinary discussion and they need to be regularly updated as new evidence emerges. Audit does not need to be expensive, but it does need the support of all staff, including managers and clinicians. Staff must understand that its purpose is not to identify errors and punish mistakes but to improve clinical care.