A prospective study of maternal, fetal and neonatal outcomes in the setting of cesarean section in low- and middle-income countries

INTRODUCTION

Cesarean section (CS) rates are increasing globally with an unclear effect on pregnancy outcomes. The study objective was to quantify maternal and perinatal morbidity and mortality associated with CS compared with vaginal delivery (VD) both within and across sites in low- and middle-income countries.

MATERIAL AND METHODS

A prospective population-based study including home and facility births in 337 153 women with a VD and 47 308 women with a CS from 2010 to 2015 was performed in Guatemala, India, Kenya, Pakistan, Zambia and Democratic Republic of Congo. Women were enrolled during pregnancy; delivery and 6-week follow-up data were collected.

RESULTS

Across all sites, CS rates increased from 8.6% to 15.2%, but remained low in African sites. Younger, nulliparous women were more likely to have a CS, as were women with higher education and those delivering an infant weighing 1500-2499 g. Across all sites, maternal and neonatal mortality was higher, and stillbirths were lower, in pregnancies delivered by CS. Antepartum and postpartum complications as well as obstetric interventions and treatments were more common among women who underwent CS. In stratified analyses, all outcomes were worse in women with a CS compared with VD in African compared to non-African sites.

CONCLUSIONS

CS rates increased across all sites during the study period, but at more pronounced rates in the non-African sites. CS was associated with reduced postpartum hemorrhage and lower rates of stillbirths in the non-African sites. In the African sites, CS was associated with an increase in all adverse outcomes. Further studies are necessary to better understand the increase in adverse outcomes with CS in the African sites.

Interdisciplinary Postdoctoral Training in Global Health Through a Novel Joint Project for Trainees from Diverse Disciplines: Benefits, Risks, and Observations

Postdoctoral training programs are usually highly individualized arrangements between trainees and a limited number of senior mentors in their field, an approach that contrasts with current trends in public health education that promote interdisciplinary training to spur innovation. Herein, we describe an alternative model for postdoctoral training for a group of fellows from distinct disciplines. Fellows work with mentors from diverse fields to create a joint research project or a group of complementary projects, with the goal of developing a new device, intervention, or innovation to address a global health problem. The perceived benefits, challenges, and limitations of this team approach to interdisciplinary postdoctoral training are presented.

Reducing neonatal mortality associated with preterm birth: gaps in knowledge of the impact of antenatal corticosteroids on preterm birth outcomes in low-middle income countries

The Global Network's Antenatal Corticosteroids Trial (ACT), was a multi-country, cluster-randomized trial to improve appropriate use of antenatal corticosteroids (ACS) in low-resource settings in low-middle income countries (LMIC). ACT substantially increased ACS use in the intervention clusters, but the intervention failed to show benefit in the targeted < 5th percentile birth weight infants and was associated with increased neonatal mortality and stillbirth in the overall population. In this issue are six papers which are secondary analyses related to ACT that explore potential reasons for the increase in adverse outcomes overall, as well as site differences in outcomes. The African sites appeared to have increased neonatal mortality in the intervention clusters while the Guatemalan site had a significant reduction in neonatal mortality, perhaps related to a combination of ACS and improving obstetric care in the intervention clusters. Maternal and neonatal infections were increased in the intervention clusters across all sites and increased infections are a possible partial explanation for the increase in neonatal mortality and stillbirth in the intervention clusters, especially in the African sites. The analyses presented here provide guidance for future ACS trials in LMIC. These include having accurate gestational age dating of study subjects and having care givers who can diagnose conditions leading to preterm birth and predict which women likely will deliver in the next 7 days. All study subjects should be followed through delivery and the neonatal period, regardless of when they deliver. Clearly defined measures of maternal and neonatal infection should be utilized. Trials in low income country facilities including clinics and those without newborn intensive care seem to be of the highest priority.

A prospective study of maternal, fetal and neonatal deaths in low- and middle-income countries

OBJECTIVE

To quantify maternal, fetal and neonatal mortality in low- and middle-income countries, to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths.

METHODS

A prospective study of pregnancy outcomes was performed in 106 communities at seven sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. Pregnant women were enrolled and followed until six weeks postpartum.

FINDINGS

Between 2010 and 2012, 214,070 of 220,235 enrolled women (97.2%) completed follow-up. The maternal mortality ratio was 168 per 100,000 live births, ranging from 69 per 100,000 in Argentina to 316 per 100,000 in Pakistan. Overall, 29% (98/336) of maternal deaths occurred around the time of delivery: most were attributed to haemorrhage (86/336), pre-eclampsia or eclampsia (55/336) or sepsis (39/336). Around 70% (4349/6213) of stillbirths were probably intrapartum; 34% (1804/5230) of neonates died on the day of delivery and 14% (755/5230) died the day after. Stillbirths were more common in women who died than in those alive six weeks postpartum (risk ratio, RR: 9.48; 95% confidence interval, CI: 7.97-11.27), as were perinatal deaths (RR: 4.30; 95% CI: 3.26-5.67) and 7-day (RR: 3.94; 95% CI: 2.74-5.65) and 28-day neonatal deaths (RR: 7.36; 95% CI: 5.54-9.77).

CONCLUSION

Most maternal, fetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes. Maternal death increased the risk of perinatal and neonatal death. Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality.

Perinatal outcomes of multiple-gestation pregnancies in Kenya, Zambia, Pakistan, India, Guatemala, and Argentina: a global network study

AIM

To determine the rates of multiple gestation, stillbirth, and perinatal and neonatal mortality and to determine health care system characteristics related to perinatal mortality of these pregnancies in low- and middle-income countries.

METHODS

Pregnant women residing within defined geographic boundaries located in six countries were enrolled and followed to 42 days postpartum.

RESULTS

Multiple gestations were 0.9% of births. Multiple gestations were more likely to deliver in a health care facility compared with singletons (70 and 66%, respectively, p < 0.001), to be attended by skilled health personnel (71 and 67%, p < 0.001), and to be delivered by cesarean (18 versus 9%, p < 0.001). Multiple-gestation fetuses had a relative risk (RR) for stillbirth of 2.65 (95% confidence interval [CI] 2.06, 3.41) and for perinatal mortality rate (PMR) a RR of 3.98 (95% CI 3.40, 4.65) relative to singletons (both p < 0.0001). Neither delivery in a health facility nor the cesarean delivery rate was associated with decreased PMR. Among multiple-gestation deliveries, physician-attended delivery relative to delivery by other health providers was associated with a decreased risk of perinatal mortality.

CONCLUSIONS

Multiple gestations contribute disproportionately to PMR in low-resource countries. Neither delivery in a health facility nor the cesarean delivery rate is associated with improved PMR.

Assessment of obstetric and neonatal health services in developing country health facilities

OBJECTIVE

To describe the staffing and availability of medical equipment and medications and the performance of procedures at health facilities providing maternal and neonatal care at African, Asian, and Latin American sites participating in a multicenter trial to improve emergency obstetric/neonatal care in communities with high maternal and perinatal mortality.

STUDY DESIGN

In 2009, prior to intervention, we surveyed 136 hospitals and 228 clinics in 7 sites in Africa, Asia, and Latin America regarding staffing, availability of equipment/medications, and procedures including cesarean section.

RESULTS

The coverage of physicians and nurses/midwives was poor in Africa and Latin America. In Africa, only 20% of hospitals had full-time physicians. Only 70% of hospitals in Africa and Asia had performed cesarean sections in the last 6 months. Oxygen was unavailable in 40% of African hospitals and 17% of Asian hospitals. Blood was unavailable in 80% of African and Asian hospitals.

CONCLUSIONS

Assuming that adequate facility services are necessary to improve pregnancy outcomes, it is not surprising that maternal and perinatal mortality rates in the areas surveyed are high. The data presented emphasize that to reduce mortality in these areas, resources that result in improved staffing and sufficient equipment, supplies, and medication, along with training, are required.

Facilitators and barriers to adoption of evidence-based perinatal care in Latin American hospitals: a qualitative study

Selective episiotomy and the active management of labor have been shown by numerous studies to benefit women's experience of labor as well as its outcomes. However, many Latin American public hospitals have not updated their clinical practices to reflect these findings. Limited access to new knowledge, limited time and physical resources and attitudes resistant to change are factors limiting the adoption of new practices in such hospitals. Interviews were conducted with three department heads, and focus groups were conducted with 31 physicians and midwives working in 10 public hospitals in Argentina and Uruguay. All were asked about facilitators and barriers to making changes in clinical practice. In addition, three focus groups were conducted with 16 pregnant women served by public hospitals. Responses were grouped according to stages of change in incorporating new evidence into practice. Numerous facilitators and barriers were identified by participants, as well as potential strategies for promoting change that could be incorporated into interventions. Barriers included limited access to information, negative attitudes toward changes in practice, lack of skills in performing new practices, lack of medical resources and explicit guidelines and a perceived need to practice defensive medicine. Changing long-standing clinical practice is difficult. Interventions must be adapted to translate evidence-based approaches to new cultures and contexts. Improving information access, use of role models, skill development and improved resources and support may be effective ways to overcome barriers to change in Latin American obstetric care.

Episiotomy for vaginal birth

BACKGROUND

Episiotomy is done to prevent severe perineal tears, but its routine use has been questioned. The relative effects of midline compared with midlateral episiotomy are unclear.

OBJECTIVES

The objective of this review was to assess the effects of restrictive use of episiotomy compared with routine episiotomy during vaginal birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Randomised trials comparing restrictive use of episiotomy with routine use of episiotomy; restrictive use of mediolateral episiotomy versus routine mediolateral episiotomy; restrictive use of midline episiotomy versus routine midline episiotomy; and use of midline episiotomy versus mediolateral episiotomy.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers.

MAIN RESULTS

Six studies were included. In the routine episiotomy group, 72.7% (1752/2409) of women had episiotomies, while the rate in the restrictive episiotomy group was 27.6% (673/2441). Compared with routine use, restrictive episiotomy involved less posterior perineal trauma (relative risk 0. 88, 95% confidence interval 0.84 to 0.92), less suturing (relative risk 0.74, 95% confidence interval 0.71 to 0.77) and fewer healing complications (relative risk 0.69, 95% confidence interval 0.56 to 0.85). Restrictive episiotomy was associated with more anterior perineal trauma (relative risk 1.79, 95% 1.55 to 2.07). There was no difference in severe vaginal or perineal trauma (relative risk 1.11, 95% confidence interval 0.83 to 1.50); dyspareunia (relative risk 1.02, 95% confidence interval 0.90 to 1.16); urinary incontinence (relative risk 0.98, 95% confidence interval 0.79 to 1.20) or several pain measures. Results for restrictive versus routine mediolateral versus midline episiotomy were similar to the overall comparison.

REVIEWER'S CONCLUSIONS

Restrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.

The Latin American Multicenter Trial on psychosocial support during pregnancy: methodology and baseline comparability. Latin American Network for Perinatal and Reproductive Research (LANPER)

This article presents the methodology and baseline findings of a large multicenter trial involving four countries from Latin America (Argentina, Brazil, Cuba, and Mexico). The study was a randomized, controlled, single-masked trial to investigate the impact of social support during pregnancy on perinatal outcomes. Pregnant women with gestational ages between 15 and 22 weeks were screened in health facilities in the four countries. Those presenting with one or more risk factors for having a low-birthweight baby were invited to join the trial. A total of 2235 women--between 500 and 600 in each country--were randomized into an intervention (n = 1110) or a control (n = 1125) group. Both groups were comparable in terms of nearly all baseline variables. The intervention group received a minimum of four visits at home by a trained health worker who provided direct emotional support, health education, and an attempt to enhance the woman's social support network. Over 90% of all women were evaluated at 36 weeks of pregnancy and soon after delivery, and 85% at the 40th day postpartum. The outcomes under study included intrauterine growth retardation, gestational age, perinatal and maternal morbidity and mortality, labor interventions, psychological distress and characteristics of the social support network, among others. This trial showed that it was possible to select, screen, randomize, visit, and evaluate a large number of women in four Latin American countries using a standardized methodology.

The Latin American trial of psychosocial support during pregnancy: a social intervention evaluated through an experimental design

Perinatal health problems are a public health priority in Latin America. Among the identified risk factors, psychological and social conditions play a crucial role. However, care during pregnancy and delivery in the region is usually hospital-centered and does not address women's psychological and social conditions. The preeminence of research on perinatal health, along with the necessity for testing interventions that represent alternative models to improve women's health, gave the Latin American Network for Perinatal and Reproductive Research grounds to develop a multicenter randomized controlled trial to evaluate a program of social support and health education during pregnancy. The conceptual framework for this study was based on an ecological model of social support, i.e. a model in which social support and health education play a synergistic role and are meant to modify stressful situations and negative health-related behaviors. The target population consisted of women attending obstetric hospitals before the 22nd gestational week, at high psychological and social risk (n = 2236). The intervention consisted of four to six home visits, carried out by social workers, and had four main components: the reinforcement of pregnant women's social support network, emotional support, health education, and the improvement of health services utilization. The main foci of the intervention were determined after an ethnographic study was carried out to identify stress-producing situations and needs for support during pregnancy. Besides the home visits, the program also offered a hot-line, an office in the hospital, a specially designed poster and booklet, and a 'guided tour' of the health institution. Since this was a multicenter trial, the program's standardization was a crucial methodological aspect that was achieved through the training course for the home-visitors team. Biological and psychosocial outcomes were measured in both experimental and control groups at the 36th week of gestational age, post-partum and at the 40th day after delivery. The attributes of the multicenter population showed an important variability, reflecting differences in the countries or hospitals' population prevalent attributes. The results of the program's implementation were analyzed, demonstrating that home visitors adapted topics discussed during the interviews to the women's conditions and the stage of pregnancy during which the visit took place.(ABSTRACT TRUNCATED AT 400 WORDS)