Outcomes to measure the effects of pharmacological interventions for pain management for women during labour and birth: a review of systematic reviews and randomised trials

BACKGROUND

Pharmacological pain management options can relieve women's pain during labour and birth. Trials of these interventions have used a wide variety of outcomes, complicating meaningful comparisons of their effects. To facilitate better assessment of the effectiveness of labour pain management in trials and meta-analyses, consensus about key outcomes and the development of a core outcome set is essential.

OBJECTIVE

To identify all outcomes used in studies of pharmacological pain management interventions during labour and birth.

DESIGN

A review of systematic reviews and their included randomised controlled trials was undertaken.

SEARCH STRATEGY

Cochrane CENTRAL was searched to identify all Cochrane systematic reviews describing pharmacological pain management options for labour and birth. Search terms included 'pain management', 'labour' and variants, with no limits on year of publication or language.

SELECTION CRITERIA

Cochrane reviews and randomised controlled trials contained within these reviews were included, provided they compared a pharmacological intervention with other pain management options, placebo or no treatment.

DATA COLLECTION AND ANALYSIS

All outcomes reported by reviews or trials were extracted and tabulated, with frequencies of individual outcomes reported.

MAIN RESULTS

Nine Cochrane reviews and 227 unique trials were included. In total, 146 unique outcomes were identified and categorised into maternal, fetal, neonatal, child, health service, provider's perspective or economic outcome domains.

CONCLUSIONS

Outcomes of pharmacological pain management interventions during labour and birth vary widely between trials. The standardisation of trial outcomes would permit the assessment of meta-analyses for best clinical practice.

TWEETABLE ABSTRACT

Outcomes to measure pharmacological pain management options during labour are highly variable and require standardisation.

Factors affecting use of magnesium sulphate for pre-eclampsia or eclampsia: a qualitative evidence synthesis

Background

Hypertensive disorders account for 14% of global maternal deaths. Magnesium sulphate (MgSO₄) is recommended for prevention and treatment of pre‐eclampsia/eclampsia. However, MgSO₄ remains underused, particularly in low‐ and middle‐income countries (LMICs).

Objective

This qualitative evidence synthesis explores perceptions and experiences of healthcare providers, administrators and policy‐makers regarding factors affecting use of MgSO₄ to prevent or treat pre‐eclampsia/eclampsia.

Search strategy

We searched MEDLINE, EMBASE, Emcare, CINAHL, Global Health and Global Index Medicus, and grey literature for studies published between January 1995 and June 2021.

Selection criteria

Primary qualitative and mixed‐methods studies on factors affecting use of MgSO₄ in healthcare settings, from the perspectives of healthcare providers, administrators and policy‐makers, were eligible for inclusion.

Data collection and analysis

We applied a thematic synthesis approach to analysis, using COM‐B behaviour change theory to map factors affecting appropriate use of MgSO₄.

Main results

We included 22 studies, predominantly from LMICs. Key themes included provider competence and confidence administering MgSO₄ (attitudes and beliefs, complexities of administering, knowledge and experience), capability of health systems to ensure MgSO₄ availability at point of use (availability, resourcing and pathways to care) and knowledge translation (dissemination of research and recommendations). Within each COM‐B domain, we mapped facilitators and barriers to physical and psychological capability, physical and social opportunity, and how the interplay between these domains influences motivation.

Conclusions

These findings can inform policy and guideline development and improve implementation of MgSO₄ in clinical care. Such action is needed to ensure this life‐saving treatment is widely available and appropriately used.

Tweetable abstract

Global qualitative review identifies factors affecting underutilisation of MgSO₄ for pre‐eclampsia and eclampsia.

Global qualitative review identifies factors affecting underutilisation of MgSO₄ for pre‐eclampsia and eclampsia.

This article includes Author Insights, a video abstract available at https://vimeo.com/manage/videos/623192027

Linked article This article is commented on by LA Magee, p. 392 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16971.

Improving the quality of maternal and newborn care in the Pacific region: A scoping review

Background

Quality care is essential for improving maternal and newborn health. Low- and middle-income Pacific Island nations face challenges in delivering quality maternal and newborn care. The aim of this review was to identify all published studies of interventions which sought to improve the quality of maternal and newborn care in Pacific low-and middle-income countries.

Methods

A scoping review framework was used. Databases and grey literature were searched for studies published between January 2000 and July 2019 which described actions to improve the quality of maternal and newborn care in Pacific low- and middle-income countries. Interventions were categorised using a four-level health system framework and the WHO quality of maternal and newborn care standards. An expert advisory group of Pacific Islander clinicians and researchers provided guidance throughout the review process.

Results

2010 citations were identified and 32 studies included. Most interventions focused on the clinical service or organisational level, such as healthcare worker training, audit processes and improvements to infrastructure. Few addressed patient experiences or system-wide improvements. Enablers to improving quality care included community engagement, collaborative partnerships, adequate staff education and training and alignment with local priorities.

Conclusions

There are several quality improvement initiatives in low- and middle-income Pacific Island nations, most at the point of health service delivery. To effectively strengthen quality maternal and newborn care in this region, efforts must broaden to improve health system leadership, deliver sustaining education programs and encompass learnings from women and their communities.

The burden of severe maternal outcomes and indicators of quality of maternal care in Nigerian hospitals: a secondary analysis comparing two large facility-based surveys

OBJECTIVE

To compare severe maternal outcomes (SMOs) from two multi-centre surveys in Nigerian hospitals, and to evaluate how the SMO burden affects quality of secondary and tertiary hospital care.

DESIGN

Two facility-based surveys of women experiencing SMO (maternal near-miss or maternal deaths).

SETTING

Sixteen secondary and five tertiary facilities in Nigeria [WHO Multi-Country Survey on Maternal and Newborn Health (WHOMCS)] and 42 public tertiary facilities in Nigeria (Nigeria Near-Miss and Maternal Death Survey).

POPULATION

371 women in WHOMCS-Nigeria and 2449 women in Nigeria Near-Miss and Maternal Death Survey who experienced SMO.

METHODS

Secondary analysis and comparison of SMO data from two surveys, stratified by facility level.

MAIN OUTCOME MEASURES

Maternal mortality ratio (MMR) per 100 000 livebirths (LB), maternal near-miss (MNM) ratio per 1000 LB, SMO ratio per 1000 LB and mortality index (deaths/SMO).

RESULTS

Maternal mortality ratio and mortality indices were highest in tertiary facilities of the WHOMCS-Nigeria (706 per 100 000; 26.7%) and the Nigeria Near-Miss and Maternal Death Survey (1088 per 100 000; 40.8%), and lower in secondary facilities of the WHOMCS-Nigeria (593 per 100 000; 17.9%). The MNM ratio and SMO ratio were highest in secondary WHOMCS-Nigeria facilities (27.2 per 1000 LB; 33.1 per 1000 LB).

CONCLUSIONS

Tertiary-level facilities in Nigeria experience unacceptably high maternal mortality rates, but secondary-level facilities had a proportionately higher burden of severe maternal outcomes. Common conditions with a high mortality index (postpartum haemorrhage, eclampsia, and infectious morbidities) should be prioritised for action. Surveillance using SMO indicators can guide quality improvement efforts and assess changes over time.

TWEETABLE ABSTRACT

2820 Nigerian women with severe maternal outcomes: high mortality in tertiary level hospitals, higher burden in secondary level.

Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis

Background

What constitutes respectful maternity care (RMC) operationally in research and programme implementation is often variable.

Objectives

To develop a conceptualisation of RMC.

Search strategy

Key databases, including PubMed, CINAHL, EMBASE, Global Health Library, grey literature, and reference lists of relevant studies.

Selection criteria

Primary qualitative studies focusing on care occurring during labour, childbirth, and/or immediately postpartum in health facilities, without any restrictions on locations or publication date.

Data collection and analysis

A combined inductive and deductive approach was used to synthesise the data; the GRADE CERQual approach was used to assess the level of confidence in review findings.

Main results

Sixty‐seven studies from 32 countries met our inclusion criteria. Twelve domains of RMC were synthesised: being free from harm and mistreatment; maintaining privacy and confidentiality; preserving women's dignity; prospective provision of information and seeking of informed consent; ensuring continuous access to family and community support; enhancing quality of physical environment and resources; providing equitable maternity care; engaging with effective communication; respecting women's choices that strengthen their capabilities to give birth; availability of competent and motivated human resources; provision of efficient and effective care; and continuity of care. Globally, women's perspectives of what constitutes RMC are quite consistent.

Conclusions

This review presents an evidence‐based typology of RMC in health facilities globally, and demonstrates that the concept is broader than a reduction of disrespectful care or mistreatment of women during childbirth. Innovative approaches should be developed and tested to integrate RMC as a routine component of quality maternal and newborn care programmes.

Tweetable abstract

Understanding respectful maternity care – synthesis of evidence from 67 qualitative studies.

Understanding respectful maternity care – synthesis of evidence from 67 qualitative studies.

Impact of stillbirths on international comparisons of preterm birth rates: a secondary analysis of the WHO multi-country survey of Maternal and Newborn Health

Objective

To evaluate the extent to which stillbirths affect international comparisons of preterm birth rates in low‐ and middle‐income countries.

Design

Secondary analysis of a multi‐country cross‐sectional study.

Setting

29 countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.

Population

258 215 singleton deliveries in 286 hospitals.

Methods

We describe how inclusion or exclusion of stillbirth affect rates of preterm births in 29 countries.

Main outcome measures

Preterm delivery.

Results

In all countries, preterm birth rates were substantially lower when based on live births only, than when based on total births. However, the increase in preterm birth rates with inclusion of stillbirths was substantially higher in low Human Development Index (HDI) countries [median 18.2%, interquartile range (17.2–34.6%)] compared with medium (4.3%, 3.0–6.7%), and high‐HDI countries (4.8%, 4.4–5.5%).

Conclusion

Inclusion of stillbirths leads to higher estimates of preterm birth rate in all countries, with a disproportionately large effect in low‐HDI countries. Preterm birth rates based on live births alone do not accurately reflect international disparities in perinatal health; thus improved registration and reporting of stillbirths are necessary.

Tweetable abstract

Inclusion of stillbirths increases preterm birth rates estimates, especially in low‐HDI countries.

Inclusion of stillbirths increases preterm birth rates estimates, especially in low‐HDI countries.

Clinical practice patterns on the use of magnesium sulphate for treatment of pre-eclampsia and eclampsia: a multi-country survey

Objective

To characterise the current clinical practice patterns regarding the use of magnesium sulphate (MgSO₄) for eclampsia prevention and treatment in a multi‐country network of health facilities and compare with international recommendations.

Design

Cross‐sectional survey.

Setting

A total of 147 health facilities in 15 countries across Africa, Latin America and Asia.

Population

Heads of obstetric departments or maternity units.

Methods

Anonymous online and paper‐based survey conducted in 2015.

Main outcome measures

Availability and use of MgSO₄; availability of a formal clinical protocol for MgSO₄ administration; and MgSO₄ dosing regimens for eclampsia prevention and treatment.

Results

Magnesium sulphate and a formal protocol for its administration were reported to be always available in 87.4% and 86.4% of all facilities, respectively. MgSO₄ was used for the treatment of mild pre‐eclampsia, severe pre‐eclampsia and eclampsia in 24.3%, 93.5% and 96.4% of all facilities, respectively. Regarding the treatment of severe pre‐eclampsia, 26.4% and 7.0% of all facilities reported using dosing regimens that were consistent with Zuspan and Pritchard regimens, respectively. Across regions, intramuscular maintenance regimens were more commonly used in the African region (45.7%) than in the Latin American (3.0%) and Asian (22.9%) regions, whereas intravenous maintenance regimens were more often used in the Latin American (94.0%) and Asian (60.0%) regions than in the African region (21.7%). Similar patterns were found for the treatment of eclampsia across regions.

Conclusions

The reported clinical use of MgSO₄ for eclampsia prevention and treatment varied widely, and was largely inconsistent with current international recommendations.

Tweetable abstract

MgSO₄ regimens for eclampsia prevention and treatment in many hospitals are inconsistent with international recommendations.

MgSO₄ regimens for eclampsia prevention and treatment in many hospitals are inconsistent with international recommendations.

Application of ICD-PM to preterm-related neonatal deaths in South Africa and United Kingdom

OBJECTIVE

We explore preterm-related neonatal deaths using the WHO application of the International Classification of Disease (ICD-10) to deaths during the perinatal period: ICD-PM as an informative case study, where ICD-PM can improve data use to guide clinical practice and programmatic decision-making.

DESIGN

Retrospective application of ICD-PM.

SETTING

South Africa, and the UK.

POPULATION

Perinatal death databases.

METHODS

Descriptive analysis of neonatal deaths and maternal conditions present.

MAIN OUTCOME MEASURES

Causes of preterm neonatal mortality and associated maternal conditions.

RESULTS

We included 98 term and 173 preterm early neonatal deaths from South Africa, and 956 term and 3248 preterm neonatal deaths from the UK. In the South African data set, the main causes of death were respiratory/cardiovascular disorders (34.7%), low birthweight/prematurity (29.2%), and disorders of cerebral status (25.5%). Amongst preterm deaths, low birthweight/prematurity (43.9%) and respiratory/cardiovascular disorders (32.4%) were the leading causes. In the data set from the UK, the leading causes of death were low birthweight/prematurity (31.6%), congenital abnormalities (27.4%), and deaths of unspecified cause (26.1%). In the preterm deaths, the leading causes were low birthweight/prematurity (40.9%) and deaths of unspecified cause (29.6%). In South Africa, 61% of preterm deaths resulted from the maternal condition of preterm spontaneous labour. Among the preterm deaths in the data set from the UK, no maternal condition was present in 36%, followed by complications of placenta, cord, and membranes (23%), and other complications of labour and delivery (22%).

CONCLUSIONS

ICD-PM can be used to appraise the maternal and newborn conditions contributing to preterm deaths, and can inform practice.

TWEETABLE ABSTRACT

ICD-PM can be used to appraise maternal and newborn contributors to preterm deaths to improve quality of care.

The WHO application of ICD-10 to deaths during the perinatal period (ICD-PM): results from pilot database testing in South Africa and United Kingdom

OBJECTIVE

To apply the World Health Organization (WHO) Application of the International Classification of Diseases, tenth revision (ICD-10) to deaths during the perinatal period: ICD-Perinatal Mortality (ICD-PM) to existing perinatal death databases.

DESIGN

Retrospective application of ICD-PM.

SETTING

South Africa, UK.

POPULATION

Perinatal death databases.

METHODS

Deaths were grouped according to timing of death and then by the ICD-PM cause of death. The main maternal condition at the time of perinatal death was assigned to each case.

MAIN OUTCOME MEASURES

Causes of perinatal mortality, associated maternal conditions.

RESULTS

In South Africa 344/689 (50%) deaths occurred antepartum, 11% (n = 74) intrapartum and 39% (n = 271) in the early neonatal period. In the UK 4377/9067 (48.3%) deaths occurred antepartum, with 457 (5%) intrapartum and 4233 (46.7%) in the neonatal period. Antepartum deaths were due to unspecified causes (59%), chromosomal abnormalities (21%) or problems related to fetal growth (14%). Intrapartum deaths followed acute intrapartum events (69%); neonatal deaths followed consequences of low birthweight/ prematurity (31%), chromosomal abnormalities (26%), or unspecified causes in healthy mothers (25%). Mothers were often healthy; 53%, 38% and 45% in the antepartum, intrapartum and neonatal death groups, respectively. Where there was a maternal condition, it was most often maternal medical conditions, and complications of placenta, cord and membranes.

CONCLUSIONS

The ICD-PM can be a globally applicable perinatal death classification system that emphasises the need for a focus on the mother-baby dyad as we move beyond 2015.

TWEETABLE ABSTRACT

ICD-PM is a global system that classifies perinatal deaths and links them to maternal conditions.

Optimising the International Classification of Diseases to identify the maternal condition in the case of perinatal death

OBJECTIVE

The WHO application of the tenth edition of the International Classification of Diseases (ICD-10) to deaths during the perinatal period (ICD Perinatal Mortality, ICD-PM) captures the essential characteristics of the mother-baby dyad that contribute to perinatal deaths. We compare the capture of maternal conditions in the existing ICD-PM with the maternal codes from the WHO application of ICD-10 to deaths during pregnancy, childbirth, and the puerperium (ICD Maternal Mortality, ICD-MM) to explore potential benefits in the quality of data received.

DESIGN

Retrospective application of ICD-PM.

SETTING

South Africa and the UK.

POPULATION

Perinatal death databases.

METHODS

The maternal conditions were classified using the ICD-PM groupings for maternal condition in perinatal death, and then mapped to the ICD-MM groupings of maternal conditions.

MAIN OUTCOME MEASURES

Main maternal conditions in perinatal deaths.

RESULTS

We reviewed 9661 perinatal deaths. The largest group (4766 cases, 49.3%) in both classifications captures deaths where there was no contributing maternal condition. Each of the other ICD-PM groups map to between three and six ICD-MM groups. If the cases in each ICD-PM group are re-coded using ICD-MM, each group becomes multiple, more specific groups. For example, the 712 cases in group M4 in ICD-PM become 14 different and more specific main disease categories when the ICD-MM is applied instead.

CONCLUSIONS

As we move towards ICD-11, the use of the more specific, applicable, and relevant codes outlined in ICD-MM for both maternal deaths and the maternal condition at the time of a perinatal death would be preferable, and would provide important additional information about perinatal deaths.

TWEETABLE ABSTRACT

Improving the capture of maternal conditions in perinatal deaths provides important actionable information.

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

BACKGROUND

Annually, around 7.9 million children are born with birth defects and the contribution of congenital malformations to neonatal mortality is generally high. Congenital malformations in children born to mothers with hypertensive disorders during pregnancy has marginally been explored.

METHODS

Country incidence of congenital malformations was estimated using data on the 310 401 livebirths of the WHO Multicountry Survey which reported information from 359 facilities across 29 countries. A random-effect logistic regression model was utilized to explore the associations between six broad categories of congenital malformations and the four maternal hypertensive disorders "Chronic Hypertension", "Preeclampsia" and "Eclampsia" and "Chronic hypertension with superimposed preeclampsia".

RESULTS

The occupied territories of Palestine presented the highest rates in all groups of malformation except for the "Lip/Cleft/Palate" category. Newborns of women with chronic maternal hypertension were associated with a 3.7 (95 % CI 1.3-10.7), 3.9 (95 % CI 1.7-9.0) and 4.2 (95 % CI 1.5-11.6) times increase in odds of renal, limb and lip/cleft/palate malformations respectively. Chronic hypertension with superimposed preeclampsia was associated with a 4.3 (95 % CI 1.3-14.4), 8.7 (95 % CI 2.5-30.2), 7.1 (95 % CI 2.1-23.5) and 8.2 (95 % CI 2.0-34.3) times increase in odds of neural tube/central nervous system, renal, limb and Lip/Cleft/Palate malformations.

CONCLUSIONS

This study shows that chronic hypertension in the maternal period exposes newborns to a significant risk of developing renal, limb and lip/cleft/palate congenital malformations, and the risk is further exacerbate by superimposing eclampsia. Additional research is needed to identify shared pathways of maternal hypertensive disorders and congenital malformations.

When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country

OBJECTIVE

To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.

DESIGN

Nationwide cross-sectional study.

SETTING

Forty-two tertiary hospitals.

POPULATION

Women admitted for pregnancy, childbirth and puerperal complications.

METHODS

All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period.

MAIN OUTCOME MEASURES

Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).

RESULTS

Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care.

CONCLUSIONS

Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care.

TWEETABLE ABSTRACT

Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

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

Objective

To generate a global reference for caesarean section (CS) rates at health facilities.

Design

Cross‐sectional study.

Setting

Health facilities from 43 countries.

Population/Sample

Thirty eight thousand three hundred and twenty‐four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing.

Methods

We hypothesised that mathematical models could determine the relationship between clinical‐obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three‐step approach to generate the global benchmark of CS rates at health facilities: creation of a multi‐country reference population, building mathematical models, and testing these models.

Main outcome measures

Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.

Results

According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C‐Model, with summary estimates ranging from 0.832 to 0.844. The C‐Model was able to generate expected CS rates adjusted for the case‐mix of the obstetric population. We have also prepared an e‐calculator to facilitate use of C‐Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).

Conclusions

This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C‐Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.

Tweetable abstract

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

Education and severe maternal outcomes in developing countries: a multicountry cross-sectional survey

OBJECTIVE

To assess the relationship between education and severe maternal outcomes among women delivering in healthcare facilities.

DESIGN

Cross-sectional study.

SETTING

Twenty-nine countries in Africa, Asia, Latin America, and the Middle East.

POPULATION

Pregnant women admitted to 359 facilities during a period of 2-4 months of data collection between 2010 and 2011.

METHODS

Data were obtained from hospital records. Stratification was based on the Human Development Index (HDI) values of the participating countries. Multivariable logistic regression analyses were conducted to assess the association between maternal morbidity and education, categorised in quartiles based on the years of formal education by country. Coverage of key interventions was assessed.

MAIN OUTCOME MEASURES

Severe maternal outcomes (near misses and death).

RESULTS

A significant association between low education and severe maternal outcomes (adjusted odds ratio, aOR, 2.07; 95% confidence interval, 95% CI, 1.46-2.95), maternal near miss (aOR 1.80; 95% CI 1.25-2.57), and maternal death (aOR 5.62; 95% CI 3.45-9.16) was observed. This relationship persisted in countries with medium HDIs (aOR 2.36; 95% CI 1.33-4.17) and low HDIs (aOR 2.65; 95% CI 1.54-2.57). Less educated women also had increased odds of presenting to the hospital in a severe condition (i.e. with organ dysfunction on arrival or within 24 hours: aOR 2.06; 95% CI 1.36-3.10). The probability that a woman received magnesium sulphate for eclampsia or had a caesarean section significantly increased as education level increased (P < 0.05).

CONCLUSIONS

Women with lower levels of education are at greater risk for severe maternal outcomes, even after adjustment for key confounding factors. This is particularly true for women in countries that have poorer markers of social and economic development.

Maternal and institutional characteristics associated with the administration of prophylactic antibiotics for caesarean section: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To illustrate the variability in the use of antibiotic prophylaxis for caesarean section, and its effect on the prevention of postoperative infections.

DESIGN

Secondary analysis of a cross-sectional study.

SETTING

Twenty-nine countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.

POPULATION

Three hundred and fifty-nine health facilities with the capacity to perform caesarean section.

METHODS

Descriptive analysis and effect estimates using multilevel logistic regression.

MAIN OUTCOME MEASURES

Coverage of antibiotic prophylaxis for caesarean section.

RESULTS

A total of 89 121 caesarean sections were performed in 332 of the 359 facilities included in the survey; 87% under prophylactic antibiotic coverage. Thirty five facilities provided 0-49% coverage and 77 facilities provided 50-89% coverage. Institutional coverage of prophylactic antibiotics varied greatly within most countries, and was related to guideline use and the practice of clinical audits, but not to the size, location of the institution or development index of the country. Mothers with complications, such as HIV infection, anaemia, or pre-eclampsia/eclampsia, were more likely to receive antibiotic prophylaxis. At the same time, mothers undergoing caesarean birth prior to labour and those with indication for scheduled deliveries were also more likely to receive antibiotic prophylaxis, despite their lower risk of infection, compared with mothers undergoing emergency caesarean section.

CONCLUSIONS

Coverage of antibiotic prophylaxis for caesarean birth may be related to the perception of the importance of guidelines and clinical audits in the facility. There may also be a tendency to use antibiotics when caesarean section has been scheduled and antibiotic prophylaxis is already included in the routine clinical protocol. This study may act as a signal to re-evaluate institutional practices as a way to identify areas where improvement is possible.

Risk factors for spontaneous and provider-initiated preterm delivery in high and low Human Development Index countries: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To evaluate how the effect of maternal complications on preterm birth varies between spontaneous and provider-initiated births, as well as among different countries.

DESIGN

Secondary analysis of a cross-sectional study.

SETTING

Twenty-nine countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.

POPULATION

299 878 singleton deliveries of live neonates or fresh stillbirths.

METHODS

Countries were categorised into very high, high, medium and low developed countries using the Human Development Index (HDI) of 2012 by the World Bank. We described the prevalence and risk of maternal complications, their effect on outcomes and their variability by country development.

MAIN OUTCOME MEASURES

Preterm birth, fresh stillbirth and early neonatal death.

RESULTS

The proportion of provider-initiated births among preterm deliveries increased with development: 19% in low to 40% in very high HDI countries. Among preterm deliveries, the socially disadvantaged were less likely, and the medically high risk were more likely, to have a provider-initiated delivery. The effects of anaemia [adjusted odds ratio (AOR), 2.03; 95% confidence interval (CI), 1.84; 2.25], chronic hypertension (AOR, 2.28; 95% CI, 1.94; 2.68) and pre-eclampsia/eclampsia (AOR, 5.03; 95% CI, 4.72; 5.37) on preterm birth were similar among all four HDI subgroups.

CONCLUSIONS

The provision of adequate obstetric care, including optimal timing for delivery in high-risk pregnancies, especially to the socially disadvantaged, could improve pregnancy outcomes. Avoiding preterm delivery in women when maternal complications, such as anaemia or hypertensive disorders, are present is important for countries at various stages of development, but may be more challenging to achieve.

Pre-eclampsia, eclampsia and adverse maternal and perinatal outcomes: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To assess the incidence of hypertensive disorders of pregnancy and related severe complications, identify other associated factors and compare maternal and perinatal outcomes in women with and without these conditions.

DESIGN

Secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health (WHOMCS) database.

SETTING

Cross-sectional study implemented at 357 health facilities conducting 1000 or more deliveries annually in 29 countries from Africa, Asia, Latin America and the Middle East.

POPULATION

All women suffering from any hypertensive disorder during pregnancy, the intrapartum or early postpartum period in the participating hospitals during the study period.

METHODS

We calculated the proportion of the pre-specified outcomes in the study population and their distribution according to hypertensive disorders' severity. We estimated the association between them and maternal deaths, near-miss cases, and severe maternal complications using a multilevel logit model.

MAIN OUTCOME MEASURES

Hypertensive disorders of pregnancy. Potentially life-threatening conditions among maternal near-miss cases, maternal deaths and cases without severe maternal outcomes.

RESULTS

Overall, 8542 (2.73%) women suffered from hypertensive disorders. Incidences of pre-eclampsia, eclampsia and chronic hypertension were 2.16%, 0.28% and 0.29%, respectively. Maternal near-miss cases were eight times more frequent in women with pre-eclampsia, and increased to up to 60 times more frequent in women with eclampsia, when compared with women without these conditions.

CONCLUSIONS

The analysis of this large database provides estimates of the global distribution of the incidence of hypertensive disorders of pregnancy. The information on the most frequent complications related to pre-eclampsia and eclampsia could be of interest to inform policies for health systems organisation.

Advanced maternal age and pregnancy outcomes: a multicountry assessment

OBJECTIVE

To assess the association between advanced maternal age (AMA) and adverse pregnancy outcomes.

DESIGN

Secondary analysis of the facility-based, cross-sectional data of the WHO Multicountry Survey on Maternal and Newborn Health.

SETTINGS

A total of 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East.

SAMPLE

A total of 308 149 singleton pregnant women admitted to the participating health facilities.

METHODS

We estimated the prevalence of pregnant women with advanced age (35 years or older). We calculated adjusted odds ratios of individual severe maternal and perinatal outcomes in these women, compared with women aged 20-34 years, using a multilevel, multivariate logistic regression model, accounting for clustering effects within countries and health facilities. The confounding factors included facility and individual characteristics, as well as country (classified by maternal mortality ratio level).

MAIN OUTCOME MEASURES

Severe maternal adverse outcomes, including maternal near miss (MNM), maternal death (MD), and severe maternal outcome (SMO), and perinatal outcomes, including preterm birth (<37 weeks of gestation), stillbirths, early neonatal mortality, perinatal mortality, low birthweight (<2500 g), and neonatal intensive care unit (NICU) admission.

RESULTS

The prevalence of pregnant women with AMA was 12.3% (37 787/308 149). Advanced maternal age significantly increased the risk of maternal adverse outcomes, including MNM, MD, and SMO, as well as the risk of stillbirths and perinatal mortalities.

CONCLUSIONS

Advanced maternal age predisposes women to adverse pregnancy outcomes. The findings of this study would facilitate antenatal counselling and management of women in this age category.

Mode and timing of twin delivery and perinatal outcomes in low- and middle-income countries: a secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To describe the mode and timing of delivery of twin pregnancies at ≥34 weeks of gestation and their association with perinatal outcomes.

DESIGN

Secondary analysis of a cross-sectional study.

POPULATION

Twin deliveries at ≥34 weeks of gestation from 21 low- and middle-income countries participating in the WHO Multicountry Survey on Maternal and Newborn Health.

METHODS

Descriptive analysis and effect estimates using multilevel logistic regression.

MAIN OUTCOME MEASURES

Stillbirth, perinatal mortality, and neonatal near miss (use of selected life saving interventions at birth).

RESULTS

The average length of gestation at delivery was 37.6 weeks. Of all twin deliveries, 16.8 and 17.6% were delivered by caesarean section before and after the onset of labour, respectively. Prelabour caesarean delivery was associated with older maternal age, higher institutional capacity and wealth of the country. Compared with spontaneous vaginal delivery, lower risks of neonatal near miss (adjusted odds ratio, aOR, 0.63; 95% confidence interval, 95% CI, 0.44-0.94) were found among prelabour caesarean deliveries. A lower risk of early neonatal mortality (aOR 0.12; 95% CI 0.02-0.56) was also observed among prelabour caesarean deliveries with nonvertex presentation of the first twin. The week of gestation with the lowest rate of prospective fetal death varied by fetal presentation: 37 weeks for vertex-vertex; 39 weeks for vertex-nonvertex; and 38 weeks for a nonvertex first twin.

CONCLUSIONS

The prelabour caesarean delivery rate among twins varied largely between countries, probably as a result of overuse of caesarean delivery in wealthier countries and limited access to caesarean delivery in low-income countries. Prelabour delivery may be beneficial when the first twin is nonvertex. International guidelines for optimal twin delivery methods are needed.

Comparison of a high-density genetic linkage map to genome features in the model grass Brachypodium distachyon

The small annual grass Brachypodium distachyon (Brachypodium) is rapidly emerging as a powerful model system to study questions unique to the grasses. Many Brachypodium resources have been developed including a whole genome sequence, highly efficient transformation and a large germplasm collection. We developed a genetic linkage map of Brachypodium using single nucleotide polymorphism (SNP) markers and an F(2) mapping population of 476 individuals. SNPs were identified by targeted resequencing of single copy genomic sequences. Using the Illumina GoldenGate Genotyping platform we placed 558 markers into five linkage groups corresponding to the five chromosomes of Brachypodium. The unusually long total genetic map length, 1,598 centiMorgans (cM), indicates that the Brachypodium mapping population has a high recombination rate. By comparing the genetic map to genome features we found that the recombination rate was positively correlated with gene density and negatively correlated with repetitive regions and sites of ancestral chromosome fusions that retained centromeric repeat sequences. A comparison of adjacent genome regions with high versus low recombination rates revealed a positive correlation between interspecific synteny and recombination rate.

Bacterial type IV secretion: conjugation systems adapted to deliver effector molecules to host cells

Several bacterial pathogens utilize conjugation machines to export effector molecules during infection. Such systems are members of the type IV or 'adapted conjugation' secretion family. The prototypical type IV system is the Agrobacterium tumefaciens T-DNA transfer machine, which delivers oncogenic nucleoprotein particles to plant cells. Other pathogens, including Bordetella pertussis, Legionella pneumophila, Brucellaspp. and Helicobacter pylori, use type IV machines to export effector proteins to the extracellular milieu or the mammalian cell cytosol.

[Legal social status of management with portable liquid oxygen devices in Germany]

This survey is based on three successful German sociolegal court proceedings instituted against relevant statutory medical cost bearers in respect of providing pulmonary patients with portable light-weight oxygen equipment. The sociolegally relevant indications for liquid oxygen treatment are described contrasting with conventional oxygen suppliers such as concentrators or steel flasks. Also detailed are the sociolegally appropriate prescription procedures for patients suffering from chronic respiratory insufficiency who can be mobilised by treatment with oxygen.

Cell biology of Legionella pneumophila

Legionella pneumophila is the causative agent of a potentially fatal form of pneumonia named Legionnaires' disease. L. pneumophila survives and replicates inside macrophages by preventing phagosome-lysosome fusion. A large number of L. pneumophila genes, called dot or icm, have been identified that are required for intracellular growth. It has recently been shown that the dot/icm genes code for a putative large membrane complex that forms a type IV secretion system used to alter the endocytic pathway.

Specific molecular chaperone interactions and an ATP-dependent conformational change are required during posttranslational protein translocation into the yeast ER

The posttranslational translocation of proteins across the endoplasmic reticulum (ER) membrane in yeast requires ATP hydrolysis and the action of hsc70s (DnaK homologues) and DnaJ homologues in both the cytosol and ER lumen. Although the cytosolic hsc70 (Ssa1p) and the ER lumenal hsc70 (BiP) are homologous, they cannot substitute for one another, possibly because they interact with specific DnaJ homologues on each side of the ER membrane. To investigate this possibility, we purified Ssa1p, BiP, Ydj1p (a cytosolic DnaJ homologue), and a GST-63Jp fusion protein containing the lumenal DnaJ region of Sec63p. We observed that BiP, but not Ssa1p, is able to associate with GST-63Jp and that Ydj1p stimulates the ATPase activity of Ssa1p up to 10-fold but increases the ATPase activity of BiP by <2-fold. In addition, Ydj1p and ATP trigger the release of an unfolded polypeptide from Ssa1p but not from BiP. To understand further how BiP drives protein translocation, we purified four dominant lethal mutants of BiP. We discovered that each mutant is defective for ATP hydrolysis, fails to undergo an ATP-dependent conformational change, and cannot interact with GST-63Jp. Measurements of protein translocation into reconstituted proteoliposomes indicate that the mutants inhibit translocation even in the presence of wild-type BiP. We conclude that a conformation- and ATP-dependent interaction of BiP with the J domain of Sec63p is essential for protein translocation and that the specificity of hsc70 action is dictated by their DnaJ partners.

Isolation and characterization of Arabidopsis mutants defective in the induction of ethylene biosynthesis by cytokinin

Cytokinins elevate ethylene biosynthesis in etiolated Arabidopsis seedlings via a post-transcriptional modification of one isoform of the key biosynthetic enzyme ACC synthase. In order to begin to dissect the signaling events leading from cytokinin perception to this modification, we have isolated a series of mutants that lack the ethylene-mediated triple response in the presence of cytokinin due to their failure to increase ethylene biosynthesis. Analysis of genetic complementation and mapping revealed that these Cin mutants (cytokinin-insensitive) represent four distinct complementation groups, one of which, cin4, is allelic to the constitutive photomorphogenic mutant fus9/cop10. The Cin mutants have subtle effects on the morphology of adult plants. We further characterized the Cin mutants by analyzing ethylene biosynthesis in response to various other inducers and in adult tissues, as well as by assaying additional cytokinin responses. The cin3 mutant did not disrupt ethylene biosynthesis under any other conditions, nor did it disrupt any other cytokinin responses. Only cin2 disrupted ethylene biosynthesis in multiple circumstances. cin1 and cin2 made less anthocyanin in response to cytokinin. cin1 also displayed reduced shoot initiation in tissue culture in response to cytokinin, suggesting that it affects a cytokinin signaling element.

Recessive and dominant mutations in the ethylene biosynthetic gene ACS5 of Arabidopsis confer cytokinin insensitivity and ethylene overproduction, respectively

We identified a set of cytokinin-insensitive mutants by using a screen based on the ethylene-mediated triple response observed after treatment with low levels of cytokinins. One group of these mutants disrupts ACS5, a member of the Arabidopsis gene family that encodes 1-aminocyclopropane-1-carboxylate synthase, the first enzyme in ethylene biosynthesis. The ACS5 isoform is mainly responsible for the sustained rise in ethylene biosynthesis observed in response to low levels of cytokinin and appears to be regulated primarily by a posttranscriptional mechanism. Furthermore, the dominant ethylene-overproducing mutant eto2 was found to be the result of an alteration of the carboxy terminus of ACS5, suggesting that this domain acts as a negative regulator of ACS5 function.

Identification of linked Legionella pneumophila genes essential for intracellular growth and evasion of the endocytic pathway

Legionella pneumophila replicates within a specialized phagosome in cultured cells, a function necessary for its pathogenicity. The replicative phagosome lacks membrane marker proteins, such as the glycoprotein LAMP-1, that are indicators of the normal endocytic pathway. We describe the isolation of several Legionella genes essential for intracellular growth and evasion of the endocytic pathway, using a genetic and cell biological approach. We screened 4,960 ethyl methanesulfonate-mutagenized colonies for defects in intracellular growth and trafficking to the replicative phagosome. Six mutant strains of L. pneumophila that had severe intracellular growth defects in mouse bone marrow-derived macrophages were identified. All six mutants were found in phagosomes that colocalized with LAMP-1, indicating defects in intracellular trafficking. The growth defects of two of these strains were complemented by molecular clones from a bank constructed from a wild-type L. pneumophila strain. The inserts from these clones are located in a region of the chromosome contiguous with several other genes essential for intracellular growth. Three mutants could be complemented by single open reading frames placed in trans, one mutant by a gene termed dotH and two additional mutants by a gene termed dotO. A deletion mutation was created in a third gene, dotI, which is located directly upstream of dotH. The delta dotI strain was also defective for intracellular growth in macrophages, and this defect was complemented by a single open reading frame in trans. Based on sequence analysis and structural predictions, possible roles of dotH, dotI, and dotO in intracellular growth are discussed.

Conjugative transfer by the virulence system of Legionella pneumophila

Legionella pneumophila, the causative agent of Legionnaires' pneumonia, replicates within alveolar macrophages by preventing phagosome-lysosome fusion. Here, a large number of mutants called dot (defective for organelle trafficking) that were unable to replicate intracellularly because of an inability of the bacteria to alter the endocytic pathway of macrophages were isolated. The dot virulence genes encoded a large putative membrane complex that functioned as a secretion system that was able to transfer plasmid DNA from one cell to another.

Evidence for pore-forming ability by Legionella pneumophila

Legionella pneumophila is the cause of Legionnaires' pneumonia. After Internalization by macrophages, it bypasses the normal endocytic pathway and occupies a replicative phagosome bound by endoplasmic reticulum. Here, we show that lysis of macrophages and red blood cells by L. pneumophila was dependent on dotA and other loci known to be required for proper targeting of the phagosome and replication within the host cell. Cytotoxicity occurred rapidly during a high-multiplicity infection, required close association of the bacteria with the eukaryotic cell and was a form of necrotic cell death accompanied by osmotic lysis. The differential cytoprotective ability of high-molecular-weight polyethylene glycols suggested that osmotic lysis resulted from insertion of a pore less than 3 nm in diameter into the plasma membrane. Results concerning the uptake of membrane-impermeant fluorescent compounds of various sizes are consistent with the osmoprotection analysis. Therefore, kinetic and genetic evidence suggested that the apparent ability of L. pneumophila to insert a pore into eukaryotic membranes on initial contact may play a role in altering endocytic trafficking events within the host cell and in the establishment of a replicative vacuole.

Brefeldin A causes a defect in secretion in Saccharomyces cerevisiae

Brefeldin A (BFA) blocks secretion in mammalian cells and causes the redistribution of Golgi resident membrane proteins to the endoplasmic reticulum (Klausner, R. D., Donaldson, J. G., and Lippincott-Schwartz, J. (1992) J. Cell Biol. 116, 1071-1080). The target(s) of BFA and its mechanism of action remain unknown. The yeast Saccharomyces cerevisiae represents an ideal organism in which to identify the BFA targets, since many molecules essential for vesicular traffic have been already identified taking advantage of the powerful genetics of this system. Unfortunately, wild type S. cerevisiae strains are largely insensitive to BFA (Hayashi, T., Takatsuki, A., and Tamura, G. (1982) Agric. Biol. Chem. 46, 2241-2248). Here we demonstrate that an erg6 mutant (Gaber, R., Copple, D., Kennedy, B., Vidal, M., and Bard, M. (1989) Mol. Cell. Biol. 9, 3447-3456) defective in the biosynthesis of ergosterol is sensitive to BFA. Treatment of erg6 cells with BFA results in an arrest in growth and causes a block in secretion similar to that seen in mammalian cells treated with BFA. Our data suggest that the changes in the erg6 strain allows BFA entry and that this strain can be used to examine the molecular mechanism of BFA action.

Sec61p and BiP directly facilitate polypeptide translocation into the ER

Secretory proteins are segregated from cytosolic proteins by their translocation into the endoplasmic reticulum (ER). A modified secretory protein trapped during translocation across the ER membrane can be crosslinked to two previously identified proteins, Sec61p and BiP (Kar2p). The dependence of this cross-linking upon proteins and small molecules was examined. Mutations in SEC62 and SEC63 decrease the ability of Sec61p to be cross-linked to the secretory polypeptide trapped in translocation. ATP is also required for interaction of Sec61p with the secretory protein. Three kar2 alleles display defective translocation in vitro. Two of these alleles also decrease the ability of Sec61p to be cross-linked to the secretory protein. The third allele, while exhibiting a severe translocation defect, does not affect the interaction of Sec61p with the secretory protein. These results suggest that Sec61p is directly involved in translocation and that BiP acts at two stages of the translocation cycle.

Loss of BiP/GRP78 function blocks translocation of secretory proteins in yeast

BiP/GRP78 is an essential member of the HSP70 family that resides in the lumen of the endoplasmic reticulum. In yeast, BiP/GRP78 is encoded by the KAR2 gene. A temperature sensitive mutation was isolated in KAR2 and found to cause a rapid block in protein secretion. Secretory precursors of a number of proteins (invertase, carboxypeptidase Y, alpha-factor, and BiP) accumulated that were characteristic of a block in translocation into the lumen of the ER. Protease protection experiments confirmed that the precursors accumulated on the cytoplasmic side of the ER membrane. Moreover, depletion of wild-type KAR2 protein also resulted in a block in translocation of secretory proteins. These results implicate BiP/GRP78 function in the continued translocation of proteins into the lumen of the ER.

KAR2, a karyogamy gene, is the yeast homolog of the mammalian BiP/GRP78 gene

The yeast KAR2 gene was isolated by complementation of a mutation that blocks nuclear fusion. The predicted KAR2 protein sequence is most homologous to mammalian BiP/GRP78 and has several structural features in common with it: a functional secretory signal sequence, a yeast endoplasmic reticulum retention signal (HDEL) at the carboxyl terminus, and the absence of potential N-linked glycosylation sites. Moreover KAR2 is regulated like BiP/GRP78: the level of mRNA is increased by drug treatments and mutations that cause accumulation of secretory precursors in the endoplasmic reticulum. However, unlike BiP/GRP78, KAR2 is also regulated by heat shock. Deletion of the KAR2 gene generated a recessive lethal mutation, showing that BiP/GRP78 function is required for cell viability.

Posttranslational modification of the Ha-ras oncogene protein: evidence for a third class of protein carboxyl methyltransferases

The ras oncogene products require membrane localization for their function, and this is thought to be accomplished by the addition of a palmitoyl group to a cysteine residue near the carboxyl terminus of the nascent chain. A lipidated carboxyl-terminal cysteine residue is also found in sequence-related yeast sex factors, and in at least two cases, the alpha-carboxyl group is also methyl esterified. To determine if ras proteins are themselves modified by a similar type of methylation reaction, we incubated rat embryo fibroblasts transformed with p53 and activated Ha-ras oncogenes with L-[methyl-3H]methionine under conditions in which the isotope was converted to the methyl donor S-adenosyl-L-[methyl-3H]methionine. By using an assay that detects methyl ester linkages, we found that immunoprecipitated ras proteins are in fact esterified and that the stability of these esters is consistent with a carboxyl-terminal localization. This methylation reaction may be important in regulating the interaction of ras proteins with plasma membrane components. The presence of analogous carboxyl-terminal tetrapeptide sequences in other proteins may provide a general recognition sequence for lipidation and methylation modification reactions.

The risks of unilateral nephrectomy: status of kidney donors 10 to 20 years postoperatively

We received requested follow-up information from 105 (73%) of our 144 kidney donors who had undergone unilateral nephrectomy 10 to 20 years previously. Five donors had died of unrelated causes 6 or more years postoperatively. Studies in the remaining 100 donors showed that the current mean serum creatinine concentration was 1.2 mg/dl and the mean 24-hour urinary protein value was 89 mg. Hypertension (defined as 160 mm Hg or more systolic, 95 mm Hg or more diastolic, or both) was present in 19% of the donors. In a subgroup of 66 donors who had had serial serum creatinine determinations, the renal function, as estimated on the basis of these serum creatinine values, had not deteriorated with time. Thus, we consider unilateral nephrectomy in this group of patients relatively safe. Subsequent evaluation will be necessary to ascertain whether these findings prevail.

Continuous ambulatory peritoneal dialysis. Three years' experience at the Mayo Clinic

From January 1979 through January 1982, 69 patients with end-stage renal failure of various causes were treated by continuous ambulatory peritoneal dialysis. The dialysis was adequate and stable in all except four patients; two of these four became irreversibly uremic, and the other two had inadequate ultrafiltration. Hemoglobin levels increased initially and remained stable in all but two patients. In our experience, metabolic problems included control of secondary hyperparathyroidism, adequate protein nutrition, progressive neuropathy, abnormal lipoprotein profiles, and excessive weight gain. Technical problems included recurrent peritonitis, maintenance of adequate peritoneal access, and development of abdominal hernias. In general, all but two patients remained enthusiastic about this type of therapy despite inherent problems. The long-term potential of continuous ambulatory peritoneal dialysis remains uncertain at this point, but for most patients, adequate short-term treatment by this method is a reasonable alternative to hemodialysis.