Clinical interventions to reduce stillbirths in sub-Saharan Africa: a mathematical model to estimate the potential reduction of stillbirths associated with specific obstetric conditions

OBJECTIVE

Stillbirths are among the most common adverse pregnancy outcomes, with 98% occurring in low-income countries. More than one-third occur in sub-Saharan Africa (SSA). However, the medical conditions causing stillbirths and interventions to reduce stillbirths from these conditions are not well documented. We estimated the reductions in stillbirths possible with combinations of interventions.

DESIGN

We developed a computerised model to estimate the impact of various interventions on stillbirths caused by the most common conditions. The model considered the location of obstetric care (home, clinic or hospital) and each intervention's efficacy, penetration and utilisation. Maternal transfers were also considered.

SETTING AND POPULATION

Pregnancies in SSA in 2012.

METHODS

For each condition, we created a series of scenarios involving different combinations of interventions and modelled their impact on stillbirth rates.

MAIN OUTCOME MEASURES

Stillbirths associated with various maternal and fetal conditions and the percentage reduction with various interventions.

RESULTS

Eight to ten maternal and fetal conditions were responsible for most stillbirths, but none for more than 15%. The most common conditions causing stillbirths in SSA include obstructed labour and uterine rupture, fetal distress and umbilical cord complications, fetal growth restriction, pre-eclampsia/eclampsia, and placental abruption/placenta praevia. Syphilis and malaria contribute smaller numbers. Reducing stillbirths requires appropriate diagnosis and management of each condition, usually including hospital care for monitoring and delivery, often by caesarean section. Maternal syphilis and malaria were the only conditions for which outpatient management alone reduced stillbirth.

CONCLUSIONS

Most stillbirths in low-income countries occur at term and during labour and therefore are preventable by appropriate obstetric care. Management focused on the maternal and fetal conditions that cause stillbirths is necessary to achieve stillbirth rates approaching those found in high-income countries.

TWEETABLE ABSTRACT

Reducing stillbirth incidence requires appropriate management of each causative condition and often caesarean delivery.

Role of the toxicology laboratory in suspected ingestions

The toxicology laboratory can fill an important role in improving patient care. Whether the service provided by the laboratory is specifically in support of a pediatric population or devoted more to the entire hospital population, the considerations involved in its configuration are the same. These considerations involve establishment of an open dialogue between the laboratory and clinical staff, an integrated and comprehensive analytic approach, and provision of reliable laboratory data in a timely fashion.

Homogeneous enzyme immunoassay of acetaminophen in serum

A new commercially available homogeneous enzyme immunoassay, using the glucose-6-phosphate dehydrogenase (G6PDH) catalyzed conversion of NAD to NADH, has been evaluated and applied to the determination of acetaminophen in serum. Replicate analysis of serum control samples over the range of 10-200 micrograms/mL demonstrated a within-assay coefficient of variation of less than or equal to 4.6% and a between-assay coefficient of variation of less than or equal to 5.8%. Regression analysis of two separate groups of 98 and 47 serum samples by this technic, using different reagent lots, and a HPLC reference method gave equations of y = 0.981x - 0.941 (r = 0.984) and y = 1.06x - 2.21 (r = 0.994), respectively. No interference due to hemolysis or turbidity was noted. Evaluation of samples containing 35 commonly prescribed or over the counter medications demonstrated no significant cross-reactivity. Prepared reagents were stable over a period of at least 2 months when stored at 4 degrees C. Correlations between two reagent lots were excellent (r = 0.998). A single sample can be analyzed expeditiously. The result may help evaluate a potential acetaminophen poisoning. Another way to assess this toxicity, calculation of the elimination half-life, has limitations that depend on the precision of the analysis.