Beyond maternal mortality--magnitude, interrelationship, and consequences of women's health, pregnancy-related complications and nutritional status on pregnancy outcomes

Factors associated with utilization of physical therapy services during pregnancy and after childbirth

Objective

To explore demographic and clinical factors associated with utilization of antepartum/postpartum physical therapy.

Methods

This is a secondary analysis of a cross-sectional survey of 298 women who were receiving or had received obstetric care at a medical center in southern Taiwan. Data were collected between May 2021 and May 2022 using an online questionnaire, which included demographic, medical, and obstetric details, the symptom severity questionnaires, management strategies, and experience and perception about physical therapy. Descriptive statistics, independent t-test, chi-square analysis and multivariate logistic regression model were used to analyze data.

Results

Among 298 respondents, 190 (63.8%) were pregnant and 108 (36.2%) were postpartum. Thirteen percent of pregnant participants and 27% of postpartum participants had received physical therapy during and/or after childbirth. Multivariate analyses showed that being postpartum, having an associate degree and below, and experiencing depressive symptoms were significantly associated with an increased utilization of physical therapy (postpartum: OR = 3.039, 95% CI = 1.530, 6.035; associate degree and below: OR = 2.521, 95% CI = 1.007, 6.316; depressive symptoms: OR = 3.606, 95% CI = 1.067, 12.185). The odds of utilizing physical therapy decreased with age (OR = 0.935, 95% CI = 0.874, 1.000).

Conclusions

Individual factors, such as age, education level, pregnancy status, and experience of depressive symptoms, have a significant association with utilization of antepartum/postpartum physical therapy and should be considered when developing obstetric care pathways to optimize clinical and healthcare utilization outcomes.

Determinants of maternal near miss events among women admitted to tertiary hospitals in Mogadishu, Somalia: a facility-based case-control study

BACKGROUND

A maternal near-miss is a situation in which a woman was on the verge of death but survived a life-threatening obstetric complication that happened during pregnancy, childbirth, or within 42 days after the pregnancy's termination. Survivors of near-miss events share several features with mothers who have died and identifying determinants of maternal near miss will aid in improving the capacity of the health system to reduce severe maternal morbidity and mortality. Therefore, this study was designed to identify determinants of maternal near miss incidents among women hospitalized to tertiary hospitals in Mogadishu, Somalia.

METHODS

A facility-based unmatched case-control study was conducted in four tertiary hospitals in Mogadishu from May 1 to July 31, 2021. A total of five hundred thirty-three (178 cases and 355 controls) study participants were involved in the study. The discharge period, cases were recruited consecutively as they emerged, whereas controls were chosen using systematic sampling approach based on every fifth interval of those delivered through normal spontaneous vaginal delivery. Women who were hospitalized during pregnancy, delivery, or within 42 days of termination of pregnancy and met at least one of the maternal near-miss disease specific criteria were classified as cases, while women who were admitted and gave birth by normal vaginal delivery and resealed from the hospital without experiencing severe obstetric complications were considered controls. Participants were interviewed by well-trained research assistants using pre-tested structured questionnaire and the medical records were reviewed to identify maternal near-miss cases. Data were entered into and analyzed with SPSS 25.0. Logistic regression was used, and the significance level was set at p value ≤ 0.05.

RESULTS

The most common maternal near-miss morbidities identified were severe anemia (32%), severe pre-eclampsia (19.6%), severe ante partum haemorrhage (15.0%), abortion complications (8.4%), eclampsia (6.1%), ICU admission (5.6%), severe PPH (2.8%) and severe systemic infections (2.8%). The main factors associated with maternal near-miss were rural residency [OR = 2.685, 95%CI: (1.702-4.235)], age below 20 years [OR = 2.728, 95%CI: (1.604-4.5640)], unmarried [OR = 2.18, 2.18, 95%CI (1.247-3.81)], lack of formal education [OR = 2.829, 95%CI: (1.262-6.341)], husband's unemployment [OR = 2.992, 95%CI: (1.886-4.745)], low family income [OR = 3.333, 95%CI (1.055-10.530)], first pregnancy before 18 years of age [OR = 3.091, 95% CI: (2.044-4.674)], short birth interval [OR = 5.922, 95%CI: (3.891-9.014)], previous history of obstetric complication [OR = 6.568, 95%CI: (4.286-10.066)], never attended ANC services [OR = 2.687, 95%CI: (1.802-4.006)], lack of autonomy in seeking medical help [OR = 3.538, 95%CI: (1.468-8.524)], delivery at non-health facility setting [OR = 4.672, 95%CI: (3.105-7.029)], experiencing the second delay [OR = 1.773, 95% CI: (1.212-2.595)] and stillbirth of the last pregnancy [OR = 5.543, 95%CI: (2.880-10.668)].

CONCLUSION

and recommendation. Lack of maternal education, lack of antenatal care, lack of autonomy to seek medical assistance, short birth interval, rural residence and delay in accessing obstetric services were identified as factors associated with maternal near-miss morbidity. As a result, the study suggests that those modifiable characteristics must be improved in order to avoid severe maternal complications and consequent maternal death.

Zinc supplementation for improving pregnancy and infant outcome

BACKGROUND

It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy, such as prolonged labour, atonic postpartum haemorrhage, pregnancy-induced hypertension, preterm labour and post-term pregnancies, although these associations have not yet been established. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015.

OBJECTIVES

1. To compare the effects on maternal, fetal, neonatal and infant outcomes in healthy pregnant women receiving zinc supplementation versus no zinc supplementation, or placebo. 2. To assess the above outcomes in a subgroup analysis reviewing studies performed in women who are, or are likely to be, zinc-deficient.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (3 July 2020), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of zinc supplementation versus no zinc supplementation or placebo administration during pregnancy, earlier than 27 weeks' gestation. We excluded quasi-randomised controlled trials. We intended to include studies presented only as abstracts, if they provided enough information or, if necessary, by contacting authors to analyse them against our criteria; we did not find any such studies.

DATA COLLECTION AND ANALYSIS

Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

For this update, we included 25 randomised controlled trials (RCTs) involving over 18,000 women and their babies. The overall risk of bias was low in half of the studies. The evidence suggests that zinc supplementation may result in little or no difference in reducing preterm births (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.74 to 1.03; 21 studies, 9851 participants; low-certainty evidence). Further, zinc supplementation may make little or no difference in reducing the risk of stillbirth (RR 1.22, 95% CI 0.80 to 1.88; 7 studies, 3295 participants; low-certainty evidence), or perinatal deaths (RR 1.10, 95% CI 0.81 to 1.51; 2 studies, 2489 participants; low-certainty evidence). It is unclear whether zinc supplementation reduces neonatal death, because the certainty of the evidence is very low. Finally, for other birth outcomes, zinc supplementation may make little or no difference to mean birthweight (MD 13.83, 95% CI -15.81 to 43.46; 22 studies, 7977 participants; low-certainty evidence), and probably makes little or no difference in reducing the risk of low birthweight (RR 0.94, 95% CI 0.79 to 1.13; 17 studies, 7399 participants; moderate-certainty evidence) and small-for-gestational age babies when compared to placebo or no zinc supplementation (RR 1.02, 95% CI 0.92 to 1.12; 9 studies, 5330 participants; moderate-certainty evidence). We did not conduct subgroup analyses, as very few studies used normal zinc populations.

AUTHORS' CONCLUSIONS

There is not enough evidence that zinc supplementation during pregnancy results in improvements in maternal or neonatal outcomes. Future research to address ways of improving the overall nutritional status of pregnant women, particularly in low-income regions, and not looking at zinc in isolation, should be an urgent priority.

Nutrition during Pregnancy: Findings from the National Institute of Child Health and Human Development (NICHD) Fetal Growth Studies-Singleton Cohort

BACKGROUND

Accumulating evidence indicates that maternal diets are important for optimizing maternal and offspring health. Existing research lacks comprehensive profiles of maternal diets throughout pregnancy, especially in a racially/ethnically diverse obstetrical population.

OBJECTIVE

The aim was to characterize diets in a longitudinal US pregnancy cohort by trimester, race/ethnicity, and prepregnancy BMI.

METHODS

Data were obtained from pregnant women in the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Fetal Growth Studies-Singleton cohort (2009-2013). A food-frequency questionnaire (FFQ) at 8-13 wk of gestation assessed periconception and first-trimester diet (n = 1615). Automated, self-administered, 24-h dietary recalls targeted at 16-22, 24-29, 30-33, and 34-37 wk of gestation assessed second- and third-trimester diets (n = 1817 women/6791 recalls). The Healthy Eating Index-2010 (HEI-2010) assessed diet quality (i.e., adherence to US Dietary Guidelines). Variations in weighted energy-adjusted means for foods and nutrients were examined by trimester, self-identified race/ethnicity, and self-reported prepregnancy BMI.

RESULTS

Mean (95% CI) HEI-2010 was 65.9 (64.9, 67.0) during periconception to the first trimester assessed with an FFQ and 51.6 (50.8, 52.4) and 51.5 (50.7, 52.3) during the second trimester and third trimester, respectively, assessed using 24-h recalls. No significant differences were observed between the second and third trimester in macronutrients, micronutrients, foods, or HEI-2010 components (P ≥ 0.05). Periconception to first-trimester HEI-2010 was highest among Asian/Pacific Islander [67.2 (65.9, 68.6)] and lowest among non-Hispanic Black [58.7 (57.5, 60.0)] women and highest among women with normal weight [67.2 (66.1, 68.4)] and lowest among women with obesity [63.5 (62.1, 64.9)]. Similar rankings were observed in the second/third trimesters.

CONCLUSIONS

Most pregnant women in this cohort reported dietary intakes that, on average, did not meet US Dietary Guidelines for nonpregnant individuals. Also, diet differed across race/ethnic groups and by prepregnancy BMI, with the lowest overall dietary quality in all trimesters among non-Hispanic Black women and women with obesity. No meaningful changes in dietary intake were observed between the second and third trimesters.

Metabolic profile during pregnancy in BRISA birth cohorts of Ribeirão Preto and São Luís, Brazil

During pregnancy, metabolic changes that develop in women may increase the risk of diseases and conditions that may also harm the life of the growing fetus. The aim of the present study was to identify and compare the metabolic profile (MP) during pregnancy in two birth cohorts in 2010 in the cities of Ribeirão Preto (RP) and São Luís (SL), Brazil. Pregnant women (1393 in RP and 1413 in SL) were studied; information was obtained through questionnaires in addition to anthropometric, biochemical, and blood pressure measurements. Data are presented as means and proportions. To compare the characteristics of pregnant women in both cities, chi-squared and Student's t-tests were applied, with 5% significance level. Ribeirão Preto presented higher mean values than SL for pre-gestational body mass index (24.5 vs 23 kg/m², P<0.001), systolic (108.4 vs 102.8 mmHg, P<0.001) and diastolic (65.9 vs 61.8 mmHg, P<0.001) blood pressure, total cholesterol (226.3 vs 213.7 mg/dL, P<0.001) and fractions, and glycemia (84.5 vs 80.2 mg/dL, P<0.001), except for triglycerides (P=0.135). Women from RP also showed higher rates of pre-gestational overweight and obesity compared with SL (40.1 vs 25.8%). In the present study, pregnant women in RP had a worse gestational metabolic profile than those in SL, with higher pre-gestational excess weight, indicating that nutritional transition was more advanced in the more developed city.

Potential benefits of Yoga in pregnancy-related complications during the COVID-19 pandemic and implications for working women

BACKGROUND

Pregnancy is a vulnerable period of growth and enrichment along with many physiological and psychological challenges. These changes can lead to complications if compounded by external stress and anxiety. COVID-19 has emerged as a chief stressor among the general population and is a serious threat among vulnerable populations. Therefore, there is a need for stress management tools, such as Yoga and physical exercises, both at home and at work. These can be adopted during the pandemic with proper maintenance of social distancing.

OBJECTIVE

To evaluate and compile literature that has reported the health outcomes of Yoga intervention on pregnancy at the workplace and analyzes both the restrictions as well as advantages of its beneficial effects in comparison to physical exercises.

METHODOLOGY

A comprehensive literature review was conducted utilizing PubMed and Google Scholar. The keywords used for the search include "Yoga", "work", "complications", "physical exercise", "drugs" and "COVID" indifferent permutations and combinations with "pregnancy". We compiled the literature with respect to pregnancy complications and the effects of drugs, physical activity and Yoga for preventing these complications.

RESULTS

We noted that pregnancy-related complications are becoming more prevalent because of a sedentary lifestyle, restricted physical activity and growing stress. In such situations, a home or workplace Yoga protocol can combine both exercise and mindfulness-based alleviation of anxiety for both working and non-working women.

CONCLUSION

Yoga can be effective for combating stress and anxiety besides boosting immunity in pregnant working women confronted with the COVID-19 pandemic.

What factors are associated with maternal undernutrition in eastern zone of Tigray, Ethiopia? Evidence for nutritional well-being of lactating mothers

Background

Maternal undernutrition is a pervasive health problem among Ethiopian mothers. This study aims at identifying the level of maternal undernutrition and its associated factors in Kilte Awaleo-Health and Demographic Surveillance Site (KA-HDSS), Tigray region, Ethiopia.

Methods

Nutritional status of 2260 lactating mothers was evaluated using the mid-upper-arm circumference (MUAC). Data from the vital events and verbal autopsy databases were linked to the survey and baseline recensus data to investigate the association of adult mortality from chronic causes of death (CoD) on maternal undernutrition. We employed a generalized log-binomial model to estimate the independent effects of the fitted covariates.

Results

The overall prevalence of maternal undernutrition based on MUAC < 23 cm was 38% (95% CI: 36.1, 40.1%). Recent occurrence of household morbidity (adjusted prevalence ratio (adjPR) = 1.49; 95%CI: 1.22, 1.81) was associated with increased risk of maternal undernutrition. In addition, there was a 28% higher risk (adjPR = 1.28; 95%CI: 0.98, 1.67) of maternal undernutrition for those mothers who lived in households with history of adult mortality from chronic diseases. Especially, its association with severe maternal undernutrition was strong (adjusted OR = 3.27; 95%CI: 1.48, 7.22). In contrast, good maternal health-seeking practice (adjPR = 0.86; 95%CI: 0.77, 0.96) and production of diverse food crops (adjPR = 0.72; 95%CI: 0.64, 0.81) were associated with a lower risk of maternal undernutrition. Relative to mothers with low scores of housing and environmental factors index (HAEFI), those with medium and higher scores of HAEFI had 0.81 (adjPR = 0.81; 95%CI: 0.69, 0.95) and 0.82 (adjPR = 0.82; 95%CI: 0.72, 0.95) times lower risk of maternal undernutrition, respectively.

Conclusions

Efforts to ameliorate maternal undernutrition need to consider the influence of the rising epidemiology of adult mortality from chronic diseases. Our data clearly indicate the need for channeling the integrated intervention power of nutrition-sensitive development programs with that of nutrition-specific sectoral services.

Male involvement in the maternal health care system: implication towards decreasing the high burden of maternal mortality

Background

One of the essential components of antenatal care (ANC) is birth preparedness and complication readiness (BP/CR). Strengthening BP/CR measures is one of the principal strategies to reduce maternal mortality and morbidity. The current study aimed at determining the level of men’s knowledge about obstetric danger signs, and their involvement in BP/CR among community of Northwest Ethiopia.

Method

A cross-sectional community based survey was conducted in Northwest Ethiopia from May 2016 to July 2016. Data was analyzed by the Statistical Package for the Social Sciences software Version 21.0 for Windows. Participants’ socio-demographic characteristics, knowledge of obstetric danger signs, and level of involvement in BP/CR were described using frequencies and percentages. Bivariate and multivariable logistic regressions were employed to explore the associated factors and P-value of 0.05 was used as a cut-off point to declare significant association.

Result

From 856 men who were invited for the study, 824 men agreed for the interview giving a response rate of 96.2%. Half of the men stated one danger sign that may occur during pregnancy 407(49.4%); one third during delivery 271(32.9%); and 213(25.8%) during postpartum period. Among all participants, 256(31.1%) had not made any preparations; 363(44.1%) made one step; 116(14.1%) made two steps; 82(9.9%) made three steps; 5(0.6%) made four steps; 2(0.24%) made five steps; and no one made all the birth preparation steps during the birth of their last child. BP/CR was significantly association with knowledge of at least one danger sign during pregnancy (AOR = 3.3, 95% CI: 3.1, 3.9); during delivery (AOR = 2.2, 95% CI: 1.1, 2.8); and post partum period (AOR = 1.8, 95% CI: 1.1, 2.4). Furthermore, BP/CR was found to be positively associated with being married, completing college education, escorting wife to antenatal care, and urban residence.

Conclusions

Men’s level of knowledge about obstetric danger signs, and their involvement in BP/CR was found to be very poor. Considering the importance of male involvement in the maternal health care, it is recommended to advocate policies and strategies that can improve awareness of men and enhance their engagement in the maternal care.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2139-9) contains supplementary material, which is available to authorized users.

Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus

OBJECTIVE

To identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes.

DESIGN

Systematic review and Delphi study.

METHODS

We searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists.

RESULTS

We included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators.

CONCLUSIONS

The proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable.

PROSPERO REGISTRATION NUMBER

CRD42015027351.

Burden of physical, psychological and social ill-health during and after pregnancy among women in India, Pakistan, Kenya and Malawi

Introduction

For every woman who dies during pregnancy and childbirth, many more suffer ill-health, the burden of which is highest in low-resource settings. We sought to assess the extent and types of maternal morbidity.

Methods

Descriptive observational cross-sectional study at primary-level and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi to assess physical, psychological and social morbidity during and after pregnancy. Sociodemographic factors, education, socioeconomic status (SES), quality of life, satisfaction with health, reported symptoms, clinical examination and laboratory investigations were assessed. Relationships between morbidity and maternal characteristics were investigated using multivariable logistic regression analysis.

Results

11 454 women were assessed in India (2099), Malawi (2923), Kenya (3145), and Pakistan (3287). Almost 3 out of 4 women had ≥1 symptoms (73.5%), abnormalities on clinical examination (71.3%) or laboratory investigation (73.5%). In total, 36% of women had infectious morbidity of which 9.0% had an identified infectious disease (HIV, malaria, syphilis, chest infection or tuberculosis) and an additional 32.5% had signs of early infection. HIV-positive status was highest in Malawi (14.5%) as was malaria (10.4%). Overall, 47.9% of women were anaemic, 11.5% had other medical or obstetric conditions, 25.1% reported psychological morbidity and 36.6% reported social morbidity (domestic violence and/or substance misuse). Infectious morbidity was highest in Malawi (56.5%) and Kenya (40.4%), psychological and social morbidity was highest in Pakistan (47.3%, 60.2%). Maternal morbidity was not limited to a core at-risk group; only 1.2% had all four morbidities. The likelihood of medical or obstetric, psychological or social morbidity decreased with increased education; adjusted OR (95% CI) for each additional level of education ranged from 0.79 (0.75 to 0.83) for psychological morbidity to 0.91 (0.87 to 0.95) for infectious morbidity. Each additional level of SES was associated with increased psychological morbidity (OR 1.15 (95% CI 1.10 to 1.21)) and social morbidity (OR 1.05 (95% CI 1.01 to 1.10)), but there was no difference regarding medical or obstetric morbidity. However, for each morbidity association was heterogeneous between countries.

Conclusion

Women suffer significant ill-health which is still largely unrecognised. Current antenatal and postnatal care packages require adaptation if they are to meet the identified health needs of women.

Adherence to Canada's Food Guide Recommendations during Pregnancy: Nutritional Epidemiology and Public Health

Background: In Canada, pregnant women are typically referred to Canada's Food Guide (CFG), a set of national dietary recommendations designed to promote adequate nutrient intake. Pregnant women are also advised to gain weight within the Institute of Medicine guidelines, which differ by prepregnancy body mass index (BMI). However, CFG recommendations do not account for prepregnancy BMI and provide no guidance on "less healthy" (LH) foods. Objective: The aim of this study was to score women's diets according to adherence to CFG recommendations and consumption of LH foods and to examine differences between these diet scores by prepregnancy BMI. Methods: Participants enrolled in the APrON (Alberta Pregnancy Outcomes and Nutrition) prospective cohort study completed a 24-h recall in their second trimester (n = 1630). A score was created on the basis of each daily dietary CFG recommendation met, ranging from 0 to 9. The distribution of consumption (grams per day) of 8 LH food groups was given a score of 0 (none) or 1, 2, or 3 (representing the lowest, middle, or highest tertiles, respectively) and summed giving a total LH score of 0-24. Results: There were few differences in CFG recommendations met by prepregnancy BMI status, although fewer women who were overweight or obese prepregnancy met the specific recommendation to consume 7-8 servings of fruit or vegetables/d than did those who were under- or normal weight (47% and 41% compared with 50% and 54%, respectively). Although differences were small, women who were obese prepregnancy had lower CFG scores (β = -0.28; 95% CI:-0.53, -0.02) and higher LH scores (β = 0.45; 95% CI: 0.04, 0.86) than did those who were normal weight. Conclusion: The study results suggest that more attention may need to be paid to individualized counseling on dietary recommendations that take account of prepregnancy BMI.

Reproductive health information needs and maternal literacy in the developing world

This article provides an analysis of the relationship of literacy and education in the developing world as they intertwine with reproductive health, and explores the reproductive health-related informational needs of women from these regions. Every day more than 800 women die from causes relating to pregnancy, 99% of whom are in the developing world. In 2015 16,000 children under five died every day. This article first provides a systematized review of the extensive canon of literature that explores the relationship between maternal literacy and mother and child health. A content analysis is conducted with the aim of deciphering the reproductive health-related informational needs of women in the developing world. Following, there is a discussion of interventions that have demonstrated success at ameliorating these gaps. Some of these interventions have met information needs related to family planning, HIV/AIDS, sexually transmitted infections, violence against women, sexuality, pregnancy education, and emergency obstetric care.

Saving Newborn Babies - The Benefits of Interventions in Neonatal Care in Norway over More Than 40 Years

The aim of this study was to examine the effect that the introduction of new medical interventions at birth has had on mortality among newborn babies in Norway during the period 1967-2011. During this period, there has been a significant decline in mortality, in particular for low birth weight infants. We identified four interventions that together explained about 50% of the decline in early neonatal and infant mortality: ventilators, antenatal steroids, surfactant and insure. The analyses were performed on a large set of data, encompassing more than 1.6 million deliveries (Medical Birth Registry of Norway). The richness of the data allowed us to perform several robustness tests. Our study indicates that the introduction of new medical interventions has been a very important channel through which the decline in mortality among newborn babies occurred during the second half of the last century. Copyright © 2016 John Wiley & Sons, Ltd.

Patterns and determinants of care seeking for obstetric complications in rural northwest Bangladesh: analysis from a prospective cohort study

BACKGROUND

In communities with low rates of institutional delivery, little data exist on care-seeking behavior for potentially life-threatening obstetric complications. In this analysis, we sought to describe care-seeking patterns for self-reported complications and near misses in rural Bangladesh and to identify factors associated with care seeking for these conditions.

METHODS

Utilizing data from a community-randomized controlled trial enrolling 42,214 pregnant women between 2007 and 2011, we used multivariable multinomial logistic regression to explore the association of demographic and socioeconomic factors, perceived need, and service availability with care seeking for obstetric complications or near misses. We also used multivariable multinomial logistic regression to analyze the factors associated with care seeking by type of obstetric complication (eclampsia, sepsis, hemorrhage, and obstructed labor).

RESULTS

Out of 9,576 women with data on care seeking for obstetric complications, 77% sought any care, with 29% (n = 2,150) visiting at least one formal provider and 70% (n = 5,149) visiting informal providers only. The proportion of women seeking at least one formal provider was highest among women reporting eclampsia (57%), followed by hemorrhage (28%), obstructed labor (22%), and sepsis (17%) (p < 0.001). In multivariable analyses, socioeconomic factors such as living in a household from the highest wealth quartile (Relative Risk Ratio of 1.49; 95% CI of [1.33-1.73]), women's literacy (RRR of 1.21; 95% CI of [1.05-1.42]), and women's employment (RRR of 1.10; 95% CI of [1.01-1.18]) were significantly associated with care seeking from formal providers. Service factors including living less than 10 kilometers from a health facility (RRR of 1.16; 95% CI of [1.05-1.28]) and facility availability of comprehensive obstetric services (RRR of 1.25; 95% CI of 1.04-1.36) were also significantly associated with seeking care from formal providers.

CONCLUSIONS

While the majority of women reporting obstetric complications sought care, less than a third visited health facilities. Improvements in socioeconomic factors such as maternal literacy, coupled with improved geographic access and service availability, may increase care seeking from formal facilities. Enhancing community awareness on symptoms of hemorrhage, sepsis, and obstructed labor and their consequences may promote care seeking for obstetric complications in rural Bangladesh.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

NCT00860470 .

Zinc supplementation for improving pregnancy and infant outcome

BACKGROUND

It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy such as prolonged labour, atonic postpartum haemorrhage, pregnancy-induced hypertension, preterm labour and post-term pregnancies, although many of these associations have not yet been established.

OBJECTIVES

To assess the effects of zinc supplementation in pregnancy on maternal, fetal, neonatal and infant outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2014) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of zinc supplementation in pregnancy. We excluded quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information. The quality of the evidence was assessed using GRADE.

MAIN RESULTS

We included 21 randomised controlled trials (RCTs) reported in 54 papers involving over 17,000 women and their babies. One trial did not contribute data. Trials were generally at low risk of bias. Zinc supplementation resulted in a small reduction in preterm birth (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.76 to 0.97 in 16 RCTs; 16 trials of 7637 women). This was not accompanied by a similar reduction in numbers of babies with low birthweight (RR 0.93, 95% CI 0.78 to 1.12; 14 trials of 5643 women). No clear differences were seen between the zinc and no zinc groups for any of the other primary maternal or neonatal outcomes, except for induction of labour in a single trial. No differing patterns were evident in the subgroups of women with low versus normal zinc and nutrition levels or in women who complied with their treatment versus those who did not. The GRADE quality of the evidence was moderate for preterm birth, small-for-gestational age, and low birthweight, and low for stillbirth or neonatal death and birthweight.

AUTHORS' CONCLUSIONS

The evidence for a 14% relative reduction in preterm birth for zinc compared with placebo was primarily represented by trials involving women of low income and this has some relevance in areas of high perinatal mortality. There was no convincing evidence that zinc supplementation during pregnancy results in other useful and important benefits. Since the preterm association could well reflect poor nutrition, studies to address ways of improving the overall nutritional status of populations in impoverished areas, rather than focusing on micronutrient and or zinc supplementation in isolation, should be an urgent priority.

Risk factors for reported obstetric complications and near misses in rural northwest Bangladesh: analysis from a prospective cohort study

BACKGROUND

In rural Bangladesh, more than 75% of all births occur at home in the absence of skilled birth attendants. Population-based data are lacking on the burden and risk factors for obstetric complications in settings with low rates of institutional delivery. We sought to describe the prevalence of reported complications and to analyze risk factors for obstetric complications and near misses, using data from a representative, rural setting of Bangladesh.

METHODS

This study utilized existing data on 42,214 pregnant women enrolled in a micronutrient supplementation cohort trial between 2007 and 2011 in rural northwest Bangladesh. Based on self-report of complications, women were categorized as having obstetric complications, near misses, or non-complicated pregnancies using definitions modified from the World Health Organization. Multivariable multinomial regression was used to analyze the association of biological, socioeconomic, and psychosocial variables with obstetric complications or near misses.

RESULTS

Of enrolled women, 25% (n = 10,380) were classified as having at least one obstetric complication, 2% (n = 1,004) with reported near misses, and 73% (n = 30,830) with non-complicated pregnancies. Twelve percent (n = 5,232) reported hemorrhage and 8% (n = 3,259) reported sepsis. Of the 27,241 women with live births or stillbirths, 11% (n = 2,950) reported obstructed labor and 1% (n = 328) reported eclampsia. Biological risk factors including women's age less than 18 years (Relative Risk Ratio [RRR] 1.26 95%CI:1.14-1.39) and greater than 35 years (RRR 1.23 95%CI:1.09-1.38), history of stillbirth or miscarriage (RRR 1.15 95%CI:1.07-1.22), and nulliparity (RRR 1.16 95%CI:1.02-1.29) significantly increased the risk of obstetric complications. Neither partner wanting the pregnancy increased the risk of obstetric complications (RRR 1.33 95%CI:1.20-1.46). Mid-upper arm circumference <21.5 cm increased the risk of hemorrhage and sepsis.

CONCLUSIONS

These analyses indicate a high burden of obstetric morbidity. Maternal age, nulliparity, a history of miscarriage or stillbirth, and lack of pregnancy wantedness were associated with increased risk of obstetric complications. Policies to address early marriage, unmet need for contraception, and maternal undernutrition may help mitigate this morbidity burden in rural Bangladesh.

Maternal near miss: an indicator for maternal health and maternal care

Maternal mortality is one of the important indicators used for the measurement of maternal health. Although maternal mortality ratio remains high, maternal deaths in absolute numbers are rare in a community. To overcome this challenge, maternal near miss has been suggested as a compliment to maternal death. It is defined as pregnant or recently delivered woman who survived a complication during pregnancy, childbirth or 42 days after termination of pregnancy. So far various nomenclature and criteria have been used to identify maternal near-miss cases and there is lack of uniform criteria for identification of near miss. The World Health Organization recently published criteria based on markers of management and organ dysfunction, which would enable systematic data collection on near miss and development of summary estimates. The prevalence of near miss is higher in developing countries and causes are similar to those of maternal mortality namely hemorrhage, hypertensive disorders, sepsis and obstructed labor. Reviewing near miss cases provide significant information about the three delays in health seeking so that appropriate action is taken. It is useful in identifying health system failures and assessment of quality of maternal health-care. Certain maternal near miss indicators have been suggested to evaluate the quality of care. The near miss approach will be an important tool in evaluation and assessment of the newer strategies for improving maternal health.

Uterine rupture in a teaching hospital in Mbarara, western Uganda, unmatched case- control study

BACKGROUND

Uterine rupture is one of the most devastating complications of labour that exposes the mother and foetus to grave danger hence contributing to the high maternal and perinatal mortality and morbidity in Uganda. Every year, 6000 women die due to complications of pregnancy and childbirth, uterine rupture accounts for about 8% of all maternal deaths.

METHODS

Case-control design of women with uterine rupture during 2005-2006. Controls were women who had spontaneous vaginal delivery or were delivered by caesarean section without uterine rupture as a complication. For every case, three consecutive in-patient chart numbers were picked and retrieved as controls. All available case files, labour ward and theater records were reviewed.

RESULTS

A total of 83 cases of uterine rupture out of 10940 deliveries were recorded giving an incidence of uterine rupture of 1 in 131 deliveries. Predisposing factors for uterine rupture were previous cesarean section delivery(OR 5.3 95% CI 2.7-10.2), attending < 4 antenatal visits (OR 3.3 95% CI 1.6-6.9), parity ≥ 5(OR 3.67 95% CI 2.0-6.72), no formal education (OR 2.0 95% CI 1.0-3.9), use of herbs (OR15.2 95% CI 6.2-37.0), self referral (OR 6.1 95% CI 3.3-11.2) and living in a distance >5 km from the facility (OR 10.86 95% CI 1.46-81.03). There were 106 maternal deaths during the study period giving a facility maternal mortality ratio of 1034 /100,000 live births, there were 10 maternal deaths due to uterine rupture giving a case fatality rate of 12%.

CONCLUSION

Uterine rupture still remains one of the major causes of maternal and newborn morbidity and mortality in Mbarara Regional referral Hospital in Western Uganda. Promotion of skilled attendance at birth, use of family planning among those at high risk, avoiding use of herbs during pregnancy and labour, correct use of partograph and preventing un necessary c-sections are essential in reducing the occurrences of uterine rupture.

Community effects on pregnancy intention among cohabiting women in the Philippines: implications for maternal and child health

Unintended pregnancy impacts both maternal and child health. International studies continue to emphasize the importance of reproductive health in the context of community. Only a few researchers have explored the impact of community factors on pregnancy intention using population-based surveys. This issue is of particular importance for women of low socioeconomic status in developing countries, where unintended fertility rates remain relatively high. Using the 1998 (n = 6,849) and 2003 (n = 6,773) Demographic and Health Surveys in the Philippines, we employed multilevel logistic models to explore whether community factors are associated with pregnancy intention among these women. The results showed community social capital, comprised of community-related variables, significantly predicted women's pregnancy intention, even after controlling for women's socioeconomic status, individual background factors, and spousal characteristics. The relationship between pregnancy intention and selected variables associated with community social capital, however, was not consistent across the two surveys. Community context, in general, has a significant influence on women's pregnancy intention. Specific components of the community context vary in their associations with pregnancy intention over time. In addition, differences in pregnancy intention may explain individual-level social disparities between communities. These findings suggest population health policies designed to promote maternal and child health must be context-specific.

The fetal origins of the metabolic syndrome: can we intervene?

Epidemiological studies have suggested that metabolic programming begins during fetal life and adverse events in utero are a critical factor in the etiology of chronic diseases and overall health. While the underlying molecular mechanisms linking impaired fetal development to these adult diseases are being elucidated, little is known about how we can intervene early in life to diminish the incidence and severity of these long-term diseases. This paper highlights the latest clinical and pharmaceutical studies addressing how dietary intervention in fetal and neonatal life may be able to prevent aspects of the metabolic syndrome associated with IUGR pregnancies.

Zinc supplementation for improving pregnancy and infant outcome

BACKGROUND

It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy such as prolonged labour, atonic postpartum haemorrhage, pregnancy-induced hypertension, preterm labour and post-term pregnancies, although many of these associations have not yet been established.

OBJECTIVES

To assess the effects of zinc supplementation in pregnancy on maternal, fetal, neonatal and infant outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of zinc supplementation in pregnancy. We excluded quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information.

MAIN RESULTS

We included 20 randomised controlled trials (RCTs) reported in 51 papers involving over 15,000 women and their babies. Trials were generally at low risk of bias. Zinc supplementation resulted in a small but significant reduction in preterm birth (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.76 to 0.97 in 16 RCTs; 16 trials of 7637 women). This was not accompanied by a similar reduction in numbers of babies with low birthweight (RR 0.93, 95% CI 0.78 to 1.12; 14 trials of 5643 women). No significant differences were seen between the zinc and no zinc groups for any of the other primary maternal or neonatal outcomes, except for induction of labour in a single trial. No differing patterns were evident in the subgroups of women with low versus normal zinc and nutrition levels or in women who complied with their treatment versus those who did not.

AUTHORS' CONCLUSIONS

The evidence for a 14% relative reduction in preterm birth for zinc compared with placebo was primarily represented by trials involving women of low income and this has some relevance in areas of high perinatal mortality. There was no convincing evidence that zinc supplementation during pregnancy results in other useful and important benefits. Since the preterm association could well reflect poor nutrition, studies to address ways of improving the overall nutritional status of populations in impoverished areas, rather than focusing on micronutrient and or zinc supplementation in isolation, should be an urgent priority.

Accounts of severe acute obstetric complications in rural Bangladesh

Background

As maternal deaths have decreased worldwide, increasing attention has been placed on the study of severe obstetric complications, such as hemorrhage, eclampsia, and obstructed labor, to identify where improvements can be made in maternal health. Though access to medical care is considered to be life-saving during obstetric emergencies, data on the factors associated with health care decision-making during obstetric emergencies are lacking. We aim to describe the health care decision-making process during severe acute obstetric complications among women and their families in rural Bangladesh.

Methods

Using the pregnancy surveillance infrastructure from a large community trial in northwest rural Bangladesh, we nested a qualitative study to document barriers to timely receipt of medical care for severe obstetric complications. We conducted 40 semi-structured, in-depth interviews with women reporting severe acute obstetric complications and purposively selected for conditions representing the top five most common obstetric complications. The interviews were transcribed and coded to highlight common themes and to develop an overall conceptual model.

Results

Women attributed their life-threatening experiences to societal and socioeconomic factors that led to delays in seeking timely medical care by decision makers, usually husbands or other male relatives. Despite the dominance of male relatives and husbands in the decision-making process, women who underwent induced abortions made their own decisions about their health care and relied on female relatives for advice. The study shows that non-certified providers such as village doctors and untrained birth attendants were the first-line providers for women in all categories of severe complications. Coordination of transportation and finances was often arranged through mobile phones, and referrals were likely to be provided by village doctors.

Conclusions

Strategies to increase timely and appropriate care seeking for severe obstetric complications may consider targeting of non-certified providers for strengthening of referral linkages between patients and certified facility-based providers. Future research may characterize the treatments and appropriateness of emergency care provided by ubiquitous village doctors and other non-certified treatment providers in rural South Asian settings. In addition, future studies may explore the use of mobile phones in decreasing delays to certified medical care during obstetric emergencies.

Maternal and child health in yushu, qinghai province, china

Introduction

Surmang, Qinghai Province is a rural nomadic Tibetan region in western China recently devastated by the 2010 Yushu earthquake; little information is available on access and coverage of maternal and child health services.

Methods

A cross-sectional household survey was conducted in August 2004. 402 women of reproductive age (15-50) were interviewed regarding their pregnancy history, access to and utilization of health care, and infant and child health care practices.

Results

Women's access to education was low at 15% for any formal schooling; adult female literacy was <20%. One third of women received any antenatal care during their last pregnancy. Institutional delivery and skilled birth attendance were <1%, and there were no reported cesarean deliveries. Birth was commonly attended by a female relative, and 8% of women delivered alone. Use of unsterilized instrument to cut the umbilical cord was nearly universal (94%), while coverage for tetanus toxoid immunization was only 14%. Traditional Tibetan healers were frequently sought for problems during pregnancy (70%), the postpartum period (87%), and for childhood illnesses (74%). Western medicine (61%) was preferred over Tibetan medicine (9%) for preventive antenatal care. The average time to reach a health facility was 4.3 hours. Postpartum infectious morbidity appeared to be high, but only 3% of women with postpartum problems received western medical care. 64% of recently pregnant women reported that they were very worried about dying in childbirth. The community reported 3 maternal deaths and 103 live births in the 19 months prior to the survey.

Conclusions

While China is on track to achieve national Millennium Development Goal targets for maternal and child health, women and children in Surmang suffer from substantial health inequities in access to antenatal, skilled birth and postpartum care. Institutional delivery, skilled attendance and cesarean delivery are virtually inaccessible, and consequently maternal and infant morbidity and mortality are likely high. Urgent action is needed to improve access to maternal, neonatal and child health care in these marginalized populations. The reconstruction after the recent earthquake provides a unique opportunity to link this population with the health system.

Systematic review of the magnitude and case fatality ratio for severe maternal morbidity in sub-Saharan Africa between 1995 and 2010

BACKGROUND

Analysis of severe maternal morbidity (maternal near misses) provides information on the quality of care. We assessed the prevalence/incidence of maternal near miss, maternal mortality and case fatality ratio through systematic review of studies on severe maternal morbidity in sub-Saharan Africa.

METHODS

We examined studies that reported prevalence/incidence of severe maternal morbidity (maternal near misses) during pregnancy, childbirth and postpartum period between 1996 and 2010. We evaluated the quality of studies (objectives, study design, population studied, setting and context, definition of severe acute obstetric morbidity and data collection instruments). We extracted data, using a pre-defined protocol and criteria, and estimated the prevalence or incidence of maternal near miss. The case-fatality ratios for reported maternal complications were estimated.

RESULTS

We identified 12 studies: six were cross-sectional, five were prospective and one was a retrospective review of medical records. There was variation in the setting: while some studies were health facility-based (at the national referral hospital, regional hospital or various district hospitals), others were community-based studies. The sample size varied from 557 women to 23,026. Different definitions and terminologies for maternal near miss included acute obstetric complications, severe life threatening obstetric complications and severe obstetric complications. The incidence/prevalence ratio and case-fatality ratio for maternal near misses ranged from 1.1%-10.1% and 3.1%-37.4% respectively. Ruptured uterus, sepsis, obstructed labor and hemorrhage were the commonest morbidities that were analyzed. The incidence/prevalence ratio of hemorrhage ranged from 0.06% to 3.05%, while the case fatality ratio for hemorrhage ranged from 2.8% to 27.3%. The prevalence/incidence ratio for sepsis ranged from 0.03% to 0.7%, while the case fatality ratio ranged from 0.0% to 72.7%.

CONCLUSION

The incidence/prevalence ratio and case fatality ratio of maternal near misses are very high in studies from sub-Saharan Africa. Large differences exist between countries on the prevalence/incidence of maternal near misses. This could be due to different contexts/settings, variation in the criteria used to define the maternal near misses morbidity, or rigor used carrying out the study. Future research on maternal near misses should adopt the WHO recommendation on classification of maternal morbidity and mortality.

Male involvement in birth preparedness and complication readiness for emergency obstetric referrals in rural Uganda

BACKGROUND

Every pregnant woman faces risk of life-threatening obstetric complications. A birth-preparedness package promotes active preparation and assists in decision-making for healthcare seeking in case of such complications. The aim was to assess factors associated with birth preparedness and complication-readiness as well as the level of male participation in the birth plan among emergency obstetric referrals in rural Uganda.

METHODS

This was a cross-sectional study conducted at Kabale regional hospital maternity ward among 140 women admitted as emergency obstetric referrals in antenatal, labor or the postpartum period. Data was collected on socio-demographics and birth preparedness and what roles spouses were involved in during developing the birth plan. Any woman who attended antenatal care at least 4 times, received health education on pregnancy and childbirth danger signs, saved money for emergencies, made a plan of where to deliver from and made preparations for a birth companion, was deemed as having made a birth plan. Multivariate logistic regression analysis was conducted to analyze factors that were independently associated with having a birth plan.

RESULTS

The mean age was 26.8 ± 6.6 years, while mean age of the spouse was 32.8 ± 8.3 years. Over 100 (73.8%) women and 75 (55.2%) of their spouses had no formal education or only primary level of education respectively. On multivariable analysis, Primigravidae compared to multigravidae, OR 1.8 95%CI (1.0-3.0), education level of spouse of secondary or higher versus primary level or none, OR 3.8 95%CI (1.2-11.0), formal occupation versus informal occupation of spouse, OR 1.6 95%CI (1.1-2.5), presence of pregnancy complications OR 1.4 95%CI (1.1-2.0) and the anticipated mode of delivery of caesarean section versus vaginal delivery, OR 1.6 95%CI (1.0-2.4) were associated with having a birth plan.

CONCLUSION

Individual women, families and communities need to be empowered to contribute positively to making pregnancy safer by making a birth plan.

Elementos traço e complicações obstétricas na gestação na adolescência

Minerais estão relacionados com todas as etapas de crescimento e diferenciação celular. Quando a gestação coincide com a adolescência a demanda nutricional necessária para ótimo desenvolvimento e crescimento materno e fetal aumenta consideravelmente. Apesar de existirem muitos estudos sobre as funções destes micronutrientes, pouco se sabe sobre suas atuações no resultado da gestação. Este trabalho objetivou revisar na literatura o papel do cobre, ferro, e zinco no resultado da gestação, em especial de gestantes adolescentes, focando intercorrências como baixo peso ao nascer, partos pré-termo, pré-eclampsia, abortos, dentre outras complicações associadas à gestação na adolescência. Os estudos já realizados são limitados, há a necessidade de promovê-los em países em desenvolvimento, onde a deficiência de micronutrientes e intercorrências possuem altos índices. Os benefícios da suplementação de minerais na redução da prevalência de déficits e na melhora dos estoques maternos têm sido demonstrados, mas dados sobre os benefícios potenciais para o feto são pouco conclusivos.

Healthy Eating Index during pregnancy according to pre-gravid and gravid weight status

Objective

To assess differences in the Healthy Eating Index (HEI) during pregnancy with the pre-gravid and gravid weight status of women.

Design

Cross-sectional.

Setting

Athens, Greece.

Subjects

One hundred pregnant women, inhabitants of Athens.

Results

The mean raw HEI score of the sample was 66·9 (sd 7·6) and the mean HEI adjusted for energy intake was 66·9 (sd 0·6). No difference was recorded between the adjusted HEI and different gravidities, the embryo’s sex, different income categories or education. When HEI was categorised as low, average and adequate, living in an urban residence increased the odds for demonstrating low HEI score (OR = 10·231, 95 % CI 1·300, 80·487). HEI score during pregnancy was significantly higher in participants who were either pre-gravidly underweight or of normal body weight (BW). In relation to the gestational weight status, the highest HEI scores and protein intake were shown in the underweight and of normal BW participants compared with the obese. According to the simple correspondence analysis, adequate HEI was associated with rural residence and being underweight or having normal BW during pregnancy. Low HEI was associated with overweight and obesity during pregnancy, with obesity before pregnancy and living in an urban environment. HEI was negatively correlated to the pre-conceptional and gestational BMI (r = −0·298, P ≤ 0·003 and r = −0·345, P ≤ 0·001) and to the week of gestation (r = −0·285, P ≤ 0·004).

Conclusions

Overall, the HEI of the sample was mediocre. Women who were underweight or of normal BW exhibited a better diet quality compared with obese women; thus the latter consist a population in greater need for supervised nutrition and dietary counselling during pregnancy.

Threats to safe motherhood in Honduran Miskito communities: local perceptions of factors that contribute to maternal mortality

Despite global initiatives to lower rates of maternal death, barriers to safe motherhood persist, particularly in socially and economically marginalized communities. This article describes the risks that women in Honduran Miskito villages encounter during pregnancy and childbirth. Ethnographic data are used to examine emic understandings of the underlying causes of maternal death. Participant observation, four community discussions, individual interviews with 218 women and five midwives, and a maternal mortality survey were conducted during November 2004 through November 2005. Case studies are drawn from the 55 death histories collected during the survey to illustrate the factors that contribute to maternal mortality. Community members identified poverty, gender inequality, witchcraft, and sorcery as major threats to safe motherhood. All of these factors influence women's health-related behaviors; and therefore, each issue deserves attention from public health officials. Designing appropriate interventions to improve maternal health depends on understanding the forces that increase women's vulnerability during pregnancy and childbirth. Local perspectives of risk, even when they diverge from biomedical understandings, point to specific needs, issues to address, and avenues for effective intervention.

Weekly iron and folic acid supplementation with counseling reduces anemia in adolescent girls: a large-scale effectiveness study in Uttar Pradesh, India

BACKGROUND

Weekly iron-folic acid supplementation in small-scale research trials and as administered in institutions has been demonstrated to be effective in reducing anemia in adolescent girls.

OBJECTIVE

To assess the effectiveness of weekly iron-folic acid supplementation in a large-scale project in reducing the prevalence of anemia in adolescent girls.

METHODS

The project provided weekly iron-folic acid tablets, family life education, and deworming tablets every 6 months to 150,700 adolescent school girls and non-schoolgirls of a total district population of 3,647,834. Consumption of the iron-folic acid tablets was supervised for schoolgirls but not for non-schoolgirls. Hemoglobin levels were assessed in a random sample of non-schoolgirls at 6 and 12 months and schoolgirls at 6 months. The effect of supplementation on the prevalence of anemia and the compliance rate were assessed over a 4-year period.

RESULTS

In 4 years, the overall prevalence of anemia was reduced from 73.3% to 25.4%. Hemoglobin levels and anemia prevalence were influenced significantly at 6 months. No difference in the impact on hemoglobin or anemia prevalence was observed between supervised and unsupervised girls. Counseling on the positive effects of regular weekly iron-folic acid intake contributed to a high compliance rate of over 85%. The cost of implementation was US$0.36 per beneficiary per year.

CONCLUSIONS

Weekly iron-folic acid supplementation combined with monthly education sessions and deworming every 6 months is cost-effective in reducing the prevalence of anemia in adolescent girls. Appropriate counseling, irrespective of supervision, is critical for achieving positive outcomes.

Diet and pregnancy status in Australian women

OBJECTIVE

To investigate and report the diet quality of young Australian women by pregnancy status.

DESIGN

Pregnancy status was defined as pregnant (n 606), trying to conceive (n 454), had a baby in the last 12 months (n 829) and other (n 5597). The Dietary Questionnaire for Epidemiological Studies was used to calculate diet quality using the Australian Recommended Food Score (ARFS) methodology. Nutrient intakes were compared with the Nutrient Reference Values for Australia and New Zealand.

SETTING

A population-based cohort participating in the Australian Longitudinal Study on Women's Health (ALSWH).

SUBJECTS

A nationally representative sample of Australian women, aged 25 to 30 years, who completed Survey 3 of the ALSWH. The 7486 women with biologically plausible energy intake estimates, defined as >4.5 but <20.0 MJ/d, were included in the analyses.

RESULTS

Pregnancy status was not significantly predictive of diet quality, before or after adjusting for area of residence and socio-economic status. Pregnant women and those who had given birth in the previous 12 months had marginally higher ARFS (mean (se): 30.2 (0.4) and 30.2 (0.3), respectively) than 'other' women (29.1 (0.1)). No single food group accounted for this small difference. Across all pregnancy categories there were important nutrients that did not meet the current nationally recommended levels of intake, including dietary folate and fibre.

CONCLUSION

Women do not appear to consume a wider variety of nutritious foods when planning to become pregnant or during pregnancy. Many young Australian women are failing to meet key nutrient targets as nationally recommended.

Incontinence in Malawi: Analysis of a proxy measure of vaginal fistula in a national survey

OBJECTIVE

To document the first effort to collect national lifetime prevalence data on vaginal fistulas and discern the usefulness of the measure.

METHODS

The 11,698 women successfully interviewed in the 2005 Malawi Demographic and Health Survey were asked whether they had ever experienced leakage of urine or stool from their vagina. Multivariate techniques were then used to determine factors associated with fistula symptoms.

RESULTS

The relationships between fistula symptoms and wealth and fistula symptoms and education were negative and monotonic. Rural women were 40% more likely than urban women to report fistula symptoms. Women who had experienced a stillbirth were 66% more likely to report the symptoms, and those who had experienced sexual violence were 71% more likely to report the symptoms. A crude fistula rate of 15.6 per 1000 live births was found for Malawi.

CONCLUSIONS

Survey methods may be used to capture the prevalence of vaginal fistula cases in a given country, but further work is needed to improve the sensitivity and specificity of the questions asked.

Zinc supplementation for improving pregnancy and infant outcome

BACKGROUND

It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy such as prolonged labour, atonic postpartum haemorrhage, pregnancy-induced hypertension, preterm labour and post-term pregnancies, although many of these associations have not yet been established.

OBJECTIVES

To assess the effects of zinc supplementation in pregnancy on maternal, fetal, neonatal and infant outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2007).

SELECTION CRITERIA

Randomised or quasi-randomised trials of zinc supplementation in pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, study authors were contacted for additional information.

MAIN RESULTS

We included 17 randomised controlled trials (RCTs) involving over 9000 women and their babies. Zinc supplementation resulted in a small but significant reduction in preterm birth (relative risk (RR) 0.86, 95% confidence interval (CI) 0.76 to 0.98 in 13 RCTs; 6854 women). This was not accompanied by a similar reduction in numbers of babies with low birthweight (RR 1.05 95% CI 0.94 to 1.17; 11 studies of 4941 women). No significant differences were seen between the zinc and no zinc groups for any of the other primary maternal or neonatal outcomes, except for a small effect favouring zinc for caesarean section (four trials with high heterogeneity) and for induction of labour in a single trial. No differing patterns were evident in the subgroups of women with low versus normal zinc and nutrition levels or in women who complied with their treatment versus those who did not.

AUTHORS' CONCLUSIONS

The 14% relative reduction in preterm birth for zinc compared with placebo was primarily in the group of studies involving women of low income and this has some relevance in areas of high perinatal mortality. There was no convincing evidence that zinc supplementation during pregnancy results in other useful and important benefits. Since the preterm association could well reflect poor nutrition, studies to address ways of improving the overall nutritional status of populations in impoverished areas, rather than focusing on micronutrient and or zinc supplementation in isolation, should be an urgent priority.

Effects of prenatal multimicronutrient supplements on birth weight and perinatal mortality: a randomised, controlled trial in Guinea-Bissau

OBJECTIVES

To assess the effects of daily prenatal multimicronutrient supplementation on birth weight (BW) and perinatal mortality.

DESIGN

Randomised, controlled, double masked trial.

SETTING

Urban Guinea-Bissau, West Africa.

SUBJECTS

A total of 2100 pregnant women (22+/-7 weeks pregnant at entry) were recruited through antenatal clinics, of which 1670 (79.5%) completed the trial. BW was available for 1100 live born babies.

INTERVENTIONS

Identical-looking supplements containing one (MN-1) or two (MN-2) Recommended Dietary Allowances (RDA) of 15 micronutrients, or iron and folic acid (control).

RESULTS

Mean BW among 1100 live born infants was 3050+/-498 g with 11.9% being low birth weight (LBW, BW < 2500 g). Perinatal mortality was 82 per 1000 deliveries (N = 1670), and neonatal mortality 45 per 1000 live births (N = 1599). Mean BW in MN-1 (n = 360) and MN-2 (n = 374) groups were 53 [-19; 125] and 95 [24; 166] g higher than controls (n = 366). Proportion of LBW was 13.6% in control, and 12.0 and 10.1% in the MN-1 and MN-2 groups, respectively (P = 0.33). Among anaemic women (30%), MN-2 increased BW with 218 [81; 354] g compared to controls, with a decreased risk of LBW of 69 [27; 87]%. There were apparently no differences in perinatal mortality between groups.

CONCLUSIONS

Prenatal micronutrient supplementation increased BW but did not reduce perinatal mortality in this study. Multimicronutrient supplementation with two RDA should be considered in future programmes to reduce the proportion of LBW.

Delivery-related complications and early postpartum morbidity in Dhaka, Bangladesh

OBJECTIVE

To describe delivery-related complications and postpartum morbidity of women living in slum areas of Dhaka, Bangladesh.

METHOD

From November 1993 to May 1995, 1506 women were interviewed regarding delivery-related complications and postpartum morbidities. Operational definitions were applied to maternal reports to categorize serious delivery-related complications and postpartum morbidity. Corroborating information was identified from medical records for facility-based deliveries and physical examinations by female physicians 14 to 22 days postpartum.

RESULT

Thirty-six percent of women described serious delivery-related complications and 75% of women reported postpartum morbidity. There were two maternal deaths among 1471 live births. When maternal reports were related to corroborating information, the proportion of women's reports of serious complications and morbidity appears reasonably accurate for some conditions.

CONCLUSION

A large proportion of urban slum women in Dhaka experience serious delivery-related complications and/or postpartum morbidity. Information on delivery practices that contribute to morbidity and factors that influence appropriate care seeking is needed.

Social factors and pregnancy weight gain in relation to infant birth weight: a study in public health centers in Rasht, Iran

OBJECTIVES

This study aimed to examine the relationship between total pregnancy weight gain, maternal educational level, working status and infant birth weight among mothers and infants in urban health centers in Rasht, Iran.

DESIGN

Pregnant women from six different public health centers in urban areas were studied in a prospective design. Data on women's age, parity, level of education, working status, infant birth weight, mothers' height, and prepregnancy weight and total weight gain during pregnancy were collected. The subjects were grouped based on their prepregnancy BMI and according to Institute of Medicine (IOM) recommendation for total pregnancy weight gain. The subjects were also categorized based on their years of schooling as less, intermediately and highly educated. In this study women were considered as either housewives or employed.

SETTING

Public health centers in urban areas in Rasht, Iran.

SUBJECTS

A total of 1914 pregnant women were studied.

RESULTS

These data showed that pregnancy weight gain was not different between women with normal prepregnancy weight and underweight when educational levels and working status were taken into account. Besides, pregnancy weight gain was positively related to the level of education. Analysis of variance showed that infant birth weights were not similar in mothers who gain weight less, within and above recommended ranges. In all, 60% of the normal weight women and 56.7% of the underweight women had weight gain less than the lower cutoffs of IOM recommendation. Results of logistic regression analysis showed that low level of mother's education was the only predictor for low birth weight (LBW) (>12 y education OR = 0.27(0.10-0.69)) and 5-12 y education OR = 0.62 (0.2-0.94).

CONCLUSION

These results showed that pregnancy weight gain lower recommended ranges are highly prevalent in Iranian women in public health centers in urban areas in Rasht. Moreover, mother's level of educational level may be considered as the most important determinant of birth weight and LBW in this population.

Pregnancy weight gain in Iranian women attending a cross-sectional study of public health centres in Rasht

OBJECTIVE

to investigate pregnancy weight gain in a group of Iranian women who regularly attended urban public health centres for prenatal care in Rasht, Iran.

DESIGN

an existing data study analysing routinely collected health-centre data.

SETTING

six randomly selected health centres in urban areas in Rasht.

PARTICIPANTS

704 pregnant women aged 26.1+/-5.6 years who regularly attended health centres for prenatal care and delivered between June 2002 and May 2003.

MEASUREMENTS

data on pre-pregnancy weight, height, total pregnancy weight gain, mother's age, smoking habit, parity, baby birth weight, mother's education and working status were extracted from the health records. The women were categorised based on their pre-pregnancy body mass index (BMI) as 'underweight', 'normal weight' and 'overweight' (and obese). Participants were also grouped on the basis of their years of schooling as 'low', 'intermediate' and 'high-education'; pregnancy weight gain was compared between groups and with recommended ranges.

FINDINGS

weight gain below the lower cut-off recommended by the Institute of Medicine (IOM) were 64% and 67% in underweight and normal weight women, respectively. Baby birth weight and chance of low birth weight were negatively related to pre-pregnancy BMI and pregnancy weight gain. After controlling for the differences in parity, pre-pregnancy BMI, mothers' working status and age, highly educated women (>12 years schooling) gained more weight during pregnancy than women with an intermediate (5-12 years schooling) or lower level of education (< 5 years schooling).

CONCLUSION

this study indicated that a considerable proportion of underweight and normal weight women had pregnancy weight gain below the lower cut off recommended by the IOM. These findings suggest that, in terms of pregnancy weight gain, prenatal care in the present health system is unsatisfactory. It would seem that a more effective nutritional education programme, especially for less educated pregnant women, is necessary.

Parental pregnancy intention and early childhood stunting: findings from Bolivia

BACKGROUND

This study examined the impact of maternally reported pregnancy intention, differentiating unwanted and mistimed pregnancies, on the prevalence of early childhood stunting. Additionally, it examined the influence of paternal pregnancy intention status.

METHODS

Data were collected from a nationally representative sample of women and men interviewed in the 1998 Bolivia Demographic and Health Survey. The sample was restricted to lastborn, singleton children younger than 36 months who had complete anthropometric information. Multivariable logistic regression examined the association between pregnancy intention and stunting.

RESULTS

Children from unwanted and mistimed pregnancies comprised 33% and 21% of the sample, respectively. Approximately 29% of the maternally unwanted children were stunted as compared to 19% among intended and 19% among mistimed children. Children 12-35 months (toddlers) from mistimed pregnancies (adjusted prevalence risk ratio [PR(adj)] 1.33, 95% confidence interval [CI]: 1.03-1.72) and unwanted pregnancies (PR(adj) 1.28, 95% CI: 1.04-1.56) were at about a 30% greater risk for stunting than children from intended pregnancies. Infants and toddlers with both parents reporting them as unwanted had an increased risk of being stunted as compared with children both of whose parents intended the pregnancy. No association was found for infants less than 12 months.

CONCLUSIONS

Reducing unintended pregnancies in Bolivia may decrease the prevalence of childhood growth stunting. Children born to parents reporting mistimed or unwanted pregnancies should be monitored for growth stunting, and appropriate interventions should be developed. Measurement of paternal pregnancy intention status is valuable in pregnancy intention studies.

Men's influences on women's reproductive health: medical anthropological perspectives

Reproductive health has emerged as an organizational framework that incorporates men into maternal and child health (MCH) programs. For several decades, medical anthropologists have conducted reproductive health research that explores male partners' effects on women's health and the health of children. This article summarizes exemplary research in this area, showing how ethnographic studies by medical anthropologists contribute new insights to the growing public health and demographic literature on men and reproductive health. The first half of the article begins by exploring reproductive rights, examining the concept from an anthropological perspective. As part of this discussion, the question of equality versus equity is addressed, introducing anthropological perspectives on ways to incorporate men fairly into reproductive health programs and policies. The second half of the article then turns to a number of salient examples of men's relevance in the areas of contraception, abortion, pregnancy and childbirth, infertility, and fetal harm. Medical anthropological research--as well as prominent gaps in that research--is highlighted. The article concludes with thoughts on future areas of anthropological research that may improve understandings of men's influences on women's reproductive health.

The burden of anemia among women in India

OBJECTIVE

This research investigates the prevalence and determinants of anemia among women in Andhra Pradesh. We examined differences in anemia related to social class, urban/rural location and nutrition status body mass index (BMI). We hypothesized that rural women would have higher prevalence of anemia compared to urban women, particularly among the lower income groups, and that women with low body mass index (BMI; <18.5 kg/m(2)) would have a higher risk compared to normal or overweight women.

DESIGN

The National Family Health Survey 1998/99 (NFHS-2) provides nationally representative cross-sectional survey data on women's hemoglobin status, body weight, diet, social, demographic and other household and individual level factors. Ordered logit regression analyses were applied to identify socio-economic, regional and demographic determinants of anemia.

SETTING

Andhra Pradesh, a southern Indian state.

SUBJECTS

A total of 4032 ever-married women aged 15-49 from 3872 households.

RESULTS

Prevalence of anemia was high among all women. In all 32.4% of women had mild (100-109.99 g/l for pregnant women, 100-119.99 for non-pregnant women), 14.19% had moderate (70-99.99 g/l), and 2.2% had severe anemia (<70 g/l). Protective factors include Muslim religion, reported consumption of alcohol or pulses, and high socioeconomic status, particularly in urban areas. Poor urban women had the highest rates and odds of being anemic. Fifty-two percent of thin, 50% of normal BMI, and 41% of overweight women were anemic.

CONCLUSIONS

New program strategies are needed, particularly those that improve the overall nutrition status of women of reproductive ages. This will require tailored programs across socio-economic groups and within both rural and urban areas, but particularly among the urban and rural poor.

A Diet Quality Index for Pregnancy detects variation in diet and differences by sociodemographic factors

OBJECTIVE

Methods currently used to assess nutritional status during pregnancy have limitations if one wishes to examine the overall quality of the diet. A Diet Quality Index for Pregnancy (DQI-P) was developed to reflect current nutritional recommendations for pregnancy and national dietary guidelines.

DESIGN

Dietary intake was assessed during the second trimester using a food-frequency questionnaire. The DQI-P includes eight components: % recommended servings of grains, vegetables and fruits, % recommendations for folate, iron and calcium, % energy from fat, and meal/snack patterning score. Scores can range from 0 to 80; each component contributed 10 points.

SETTING

Two public prenatal clinics in central North Carolina.

SUBJECTS

N = 2063 pregnant women who participated in the Pregnancy, Infection, and Nutrition (PIN) Study.

RESULTS

The DQI-P quantitatively differentiated diets. The mean score for the population was 56.0 (standard deviation 12.0). Women who were >30 years old, >350% of poverty, nulliparous and high school graduates had significantly higher overall DQI-P scores. Higher percentages of recommended vegetable servings were consumed by higher-income, older and better-educated women. Greater percentages of recommended intakes of folate and iron were seen among black, low-income and nulliparous women. Higher iron intakes were also seen among women who graduated high school and were less than 30 years old. Other differences were observed for intake of fat and meal/snack pattern. Because this index was based on national recommendations, the DQI-P may be a useful tool for research and public health settings to evaluating overall diet quality of pregnant women.

The impact of neonatal mortality on subsequent survival in rural Ethiopia

In countries where most deliveries occur at home and most available information is hospital-based, accurate information on neonatal mortality is difficult to obtain. This study was conducted in a rural community in Ethiopia that has been under monthly demographic surveillance since 1987. The analysis in this paper was based on data collected in the 1st decade (1987-96) and this database was used to calculate mortality incidence rates and analyse survival. The overall neonatal mortality rate was 27/1000 live births (95% CI 24.5-29.5). The rates in the early and late neonatal periods were 20 and 8/1000 live births, respectively (95% CIs 18.0-22.9 and 6.6-9.4). The mortality incidence rates show that, every day, three of every 1000 newborns die in their 1st week of life. Neonatal mortality accounted for 43% of infant mortality. If all neonates survived the 1st week of life, life expectancy would increase by 1 year. Increased risk of neonatal mortality was found to be associated with living in a rural lowland area, twin births and male gender. This paper also addresses the need for further identification of the complex environmental and behavioural risk factors for neonatal mortality and for instituting appropriate and affordable interventions to reduce neonatal mortality.

Maternal mortality in Greece (1980-1996)

OBJECTIVE

To use data from the National Statistical Service of Greece to examine trends in maternal mortality and risk factors for maternal deaths.

STUDY DESIGN

Maternal mortality in Greece has been studied from years 1980 to 1996 in total, by cause of death, by residency (urban/rural) and by maternal age. The maternal mortality ratio (MMR) has been defined as the number of deaths per 100,000 live births.

RESULTS

From years 1980 to 1996, there have been 136 maternal deaths (MMR: 7). The number of deaths has significantly decreased during this period and six major causes of death have been identified, resulting in 80% of maternal deaths. A simulation of maternal mortality between urban and rural areas has been achieved during the last decade. Also, maternal mortality rises dramatically with age.

CONCLUSIONS

Although overall rates of maternal mortality in Greece have been significantly decreased over the last years, an improved recording of maternal deaths is necessary for identifying preventable factors and developing effective interventions.

The nutrition transition is underway in India

Nutrition research in India has previously focused on the serious problem of undernutrition related to nutrient deficit and high rates of infection. Recent data from the National Family Health Survey 1998/99 (NFHS 2), however, identified a significant proportion of Indian women as overweight, coexisting with high rates of malnutrition. This paper examines the emerging nutrition transition for women living in rural and urban communities of Andhra Pradesh, India. NFHS 2 provides nationally representative data on women's weight and height. In this paper, we examine representative data from the state of Andhra Pradesh (n = 4032 women). Logistic regression analyses are applied to the data to identify socioeconomic, regional and demographic determinants of overweight and thinness. The major nutrition problem facing women continues to be undernutrition, with 37% having a low body mass index [(BMI) < 18.5 kg/m(2)]; 8% of these women are severely malnourished (BMI < 16 kg/m(2)). However, 12% of the women can be classified as overweight (BMI > 25 kg/m(2)) and 2% are obese (BMI > 30 kg/m(2)). Furthermore, in the large cities of the state in which 4% of the sample live, 37% of women are overweight or obese, whereas in the rural areas in which 74% reside, 43% have a low BMI. Women from lower socioeconomic groups are also significantly more likely to have a low BMI. Findings from the logistic regression models reveal socioeconomic status to be a more important predictor of both over- and underweight than location of residence.

Malaria prophylaxis and the reduction of anemia at childbirth

OBJECTIVES

To assess the effect of introducing chloroquine prophylaxis during pregnancy on prevalence of anemia (<10.9 g/dl) at childbirth and perinatal outcome.

METHODS

Observational study in a rural district hospital in Ghana, which compared 2803 women who received chloroquine prophylaxis during pregnancy with 3084 historical controls, who had not received prophylaxis during pregnancy. Main outcome measures were hemoglobin level at childbirth, perinatal mortality and birth weight.

RESULTS

Mean hemoglobin level before childbirth increased from 10.7 g/dl (S.D.=1.0 g/dl) to 11.0 g/dl (S.D.=0.9 g/dl). Prevalence of anemia decreased from 29.4 to 13.3% (OR=0.4 and 95% CI=0.3-0.4). Prevalence of moderately severe anemia (<9.0 g/dl) decreased from 4.4 to 3.3% (OR=0.7, 95% CI=0.6-0.97). Perinatal mortality and low birth weight (<2500 g) remained unchanged.

CONCLUSIONS

Routine chloroquine prophylaxis in pregnancy is useful in reducing anemia at childbirth in malaria-endemic regions. Fetal outcome did not improve with chloroquine prophylaxis in this study.

The lived experiences of autonomous Angolan midwives working in midwifery-led, maternity units

OBJECTIVE

to describe the lived experiences of autonomous midwives working in Angolan midwifery-led maternity units.

DESIGN

a qualitative approach using semi-structured, audiotaped interviews, in Portugese. Data were analysed in a six-step process.

SETTING

three midwifery-led maternity units in the most densely populated suburbs in the capital of Angola, Luanda. The average number of deliveries per unit was 2500 per year.

PARTICIPANTS

11 midwives from the three maternity units.

FINDINGS

four main areas emerged: society/culture, significant others, personal self and professional self. Sub-areas, concepts and supporting statements were defined in each area.

KEY CONCLUSIONS

the midwives served within a population living in rough circumstances but which maintained strong traditional roots. The midwives did not support homebirths, but did assist when needed. The midwives described their professional role as a 'calling', which was very independent. Cure, was considered more important than care, and strong emotions were expressed when discussing cases of failure. The partograph was viewed as an important instrument and continuous learning as crucial in their role as autonomous midwives.

IMPLICATIONS FOR PRACTICE

the model of a midwifery-led delivery unit described in this study may be used in other countries facing the same problems as Angola. Difficulties concerning transfer should be seriously considered as well as adequate education for the midwives. A pre-requisite in order for peripheral maternity units to have any impact on maternal morbidity and mortality, is a well-organised first-referral level.

Vitamin A or beta-carotene supplementation reduces symptoms of illness in pregnant and lactating Nepali women

The contribution of nutritional interventions to the reduction in maternal morbidity rates in developing countries is not well known. We assessed the impact of weekly vitamin A and beta-carotene supplementation on the prevalence of pregnancy and postpartum illness symptoms among 15,832 Nepali women in a placebo-controlled, double-masked, cluster-randomized trial. There was no impact of either supplement on morbidity rates reported up to 28 wk of gestation, inclusive. However, in late pregnancy (>28 wk), symptoms of nausea, faintness and night blindness were reduced with vitamin A, but not beta-carotene, supplementation. Vitamin A supplementation shortened the length of labor by 1.5 h 50 min among nulliparous and multiparous women, respectively. Both interventions reduced the postpartum prevalence of at least four loose stools and night blindness. beta-Carotene supplementation also reduced symptoms of high fever postpartum. The mean number of days of any reported illness symptoms was 3-4 per wk throughout pregnancy. Among women receiving vitamin A, the total number of days of illness symptoms accrued over the last 12 wk of pregnancy was lower by 5 d compared with the placebo recipients. We found the burden of pregnancy-related illness symptoms to be high in this rural area of Nepal where antenatal care is poor and most deliveries occur at home. Maternal vitamin A or beta-carotene supplementation resulted in a reduction in the prevalence of selected illness symptoms during late pregnancy, at the time of birth and during 6 mo postpartum, suggesting that a diet adequate in vitamin A may be important for improving women's reproductive health.