WHAT'S NEW THIS FRIDAY: FIVE ON PREVENTION OF NEONATAL MORTALITY

Thursday, 18th of April 2013

FIVE ON PREVENTION OF NEONATAL MORTALITY
MALARIA PREVENTION WITH IPTp DURING PREGNANCY REDUCES NEONATAL MORTALITY

Abstract below; full text, with figures, is at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0009438

Background

In the global context of a reduction of under-five mortality, neonatal mortality is an increasingly relevant component of this mortality. Malaria in pregnancy may affect neonatal survival, though no strong evidence exists to support this association.

Methods

In the context of a randomised, placebo-controlled trial of intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine (SP) in 1030 Mozambican pregnant women, 997 newborns were followed up until 12 months of age. There were 500 live borns to women who received placebo and 497 to those who received SP.

Findings

There were 58 infant deaths; 60.4% occurred in children born to women who received placebo and 39.6% to women who received IPTp (p = 0.136). There were 25 neonatal deaths; 72% occurred in the placebo group and 28% in the IPTp group (p = 0.041). Of the 20 deaths that occurred in the first week of life, 75% were babies born to women in the placebo group and 25% to those in the IPTp group (p = 0.039). IPTp reduced neonatal mortality by 61.3% (95% CI 7.4%, 83.8%); p = 0.024].

Conclusions

Malaria prevention with SP in pregnancy can reduce neonatal mortality. Mechanisms associated with increased malaria infection at the end of pregnancy may explain the excess mortality in the malaria less protected group. Alternatively, SP may have reduced the risk of neonatal infections. These findings are of relevance to promote the implementation of IPTp with SP, and provide insights into the understanding of the pathophysiological mechanisms through which maternal malaria affects fetal and neonatal health.

Trial Registration

ClinicalTrials.gov NCT00209781

Citation: Menéndez C, Bardají A, Sigauque B, Sanz S, Aponte JJ, et al. (2010) Malaria Prevention with IPTp during Pregnancy Reduces Neonatal Mortality. PLoS ONE 5(2): e9438. doi:10.1371/journal.pone.0009438

Editor: Nicholas J. White, Mahidol University, Thailand

Received: September 7, 2009; Accepted: January 28, 2010; Published: February 26, 2010

Copyright: © 2010 Menéndez et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The study received financial support from the Banco de Bilbao, Vizcaya, Argentaria Foundation (grant number BBVA 02-0). The Centro de Investigacao em Saude de Manhiça(CISM), receives major core funding from the Spanish Agency for International Cooperation (AECI). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

NEONATAL MORTALITY IN SUDAN: ANALYSIS OF THE SUDAN HOUSEHOLD SURVEY, 2010

Amal O Bashir, Ghada H Ibrahim, Igbal A Bashier and Ishag Adam

BMC Public Health 2013, 13:287 doi:10.1186/1471-2458-13-287

Published: 1 April 2013

Abstract (provisional); full text is at http://www.biomedcentral.com/content/pdf/1471-2458-13-287.pdf

Background

Sudan is classified as having insufficient progress in achieving the Millennium Development Goal (MDG-4), where the levels of child and infant mortality are among the highest in the region and the world. This study investigated factors associated with neonatal mortality in Sudan. Neonatal death is defined as death within the first 28 days of life.

Methods

This study analysed data from the Sudan Household Health Survey 2nd round, which was carried out in 2010. Total of 6,198 live-born infants delivered within the two years preceding the survey were included as the study population. Multivariate logistic regression was used to model neonatal mortality as a function of maternal health parameters, socioeconomic indicators and the sex of the child.

Results

There were 189 neonatal deaths out of 6,198 live births (3.0%). In the multiple logistic regression, the factors associated with neonatal mortality were advanced maternal age (>= 40 years; OR = 2.4; 95% CI: 1.21, 4.78, p = 0.012), poor household wealth index (OR = 1.6; 95% CI: 1.18, 2.47, p = 0.005), male child (OR = 1.8; 95% CI: 1.31, 2.42, p < 0.001), delivery of baby by Caesarean section (OR = 1.6; 95% CI: 1.78, 2.42, p = 0.013) and delivery complications (OR = 1.4; 95% CI: 1.18, 2.15, p = 0.002).

Conclusion

Public health interventions which target neonatal mortality reduction should adopt a risk-factor-based approach to detect pregnancy complications early and once identified, the health system should be strengthened so that these complications can be dealt with adequately.

THE EFFECTIVENESS OF EMERGENCY OBSTETRIC REFERRAL INTERVENTIONS IN DEVELOPING COUNTRY SETTINGS: A SYSTEMATIC REVIEW

Abstract and editors’ summary below; full text, with tables, is at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001264

Abstract

Background

Pregnancy complications can be unpredictable and many women in developing countries cannot access health facilities where life-saving care is available. This study assesses the effects of referral interventions that enable pregnant women to reach health facilities during an emergency, after the decision to seek care is made.

Methods and findings

Selected bibliographic databases were searched with no date or language restrictions. Randomised controlled trials and quasi experimental study designs with a comparison group were included. Outcomes of interest included maternal and neonatal mortality and other intermediate measures such as service utilisation. Two reviewers independently selected, appraised, and extracted articles using predefined fields. Forest plots, tables, and qualitative summaries of study quality, size, and direction of effect were used for analysis.

Nineteen studies were included. In South Asian settings, four studies of organisational interventions in communities that generated funds for transport reduced neonatal deaths, with the largest effect seen in India (odds ratio 0·48 95% CI 0·34–0·68). Three quasi experimental studies from sub-Saharan Africa reported reductions in stillbirths with maternity waiting home interventions, with one statistically significant result (OR 0.56 95% CI 0.32–0.96). Effects of interventions on maternal mortality were unclear. Referral interventions usually improved utilisation of health services but the opposite effect was also documented. The effects of multiple interventions in the studies could not be disentangled. Explanatory mechanisms through which the interventions worked could not be ascertained.

Conclusions

Community mobilisation interventions may reduce neonatal mortality but the contribution of referral components cannot be ascertained. The reduction in stillbirth rates resulting from maternity waiting homes needs further study. Referral interventions can have unexpected adverse effects. To inform the implementation of effective referral interventions, improved monitoring and evaluation practices are necessary, along with studies that develop better understanding of how interventions work.

Please see later in the article for the Editors' Summary

Citation: Hussein J, Kanguru L, Astin M, Munjanja S (2012) The Effectiveness of Emergency Obstetric Referral Interventions in Developing Country Settings: A Systematic Review. PLoS Med 9(7): e1001264. doi:10.1371/journal.pmed.1001264

Academic Editor: Cynthia K. Stanton, The Johns Hopkins Bloomberg School of Public Health, United States of America

Received: December 16, 2011; Accepted: May 25, 2012; Published: July 10, 2012

Copyright: © 2012 Hussein et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This work was completed with funding from the Department of International Development (DFID). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: SM and JH were authors on some of the studies considered for inclusion in this systematic review and were involved in the implementation of the interventions. They were not involved in assessment of their studies. All other authors have declared that no competing interests exist.

Abbreviations: OR, odds ratio; RCT, randomised controlled trial; TBA, traditional birth attendant

Editors' Summary

Background

Every year, about 350,000 women die from pregnancy- or childbirth-related complications. Almost all of these “maternal” deaths occur in developing countries. In sub-Saharan Africa, for example, the maternal mortality ratio (MMR, the number of maternal deaths per 100,000 live births) is 500 and a woman's life-time risk of dying from complications of pregnancy or childbirth is 1 in 39. By contrast, the MMR in industrialized countries is 12 and women have a life-time risk of maternal death of 1 in 4,700. Most maternal deaths are caused by hemorrhage (severe bleeding after childbirth), post-delivery infections, obstructed (difficult) labor, and blood pressure disorders during pregnancy, all of which are preventable or treatable conditions. Unfortunately, it is hard to predict which women will develop pregnancy complications, many complications rapidly become life-threatening and, in developing countries, women often deliver at home, far from emergency obstetric services; obstetrics deals with the care of women and their children during pregnancy, childbirth, and the postnatal period.

Why Was This Study Done?

It should be possible to reduce maternal deaths (and the deaths of babies during pregnancy, childbirth, and early life) in developing countries by ensuring that pregnant women are referred to emergency obstetric services quickly when the need arises. Unfortunately, in such countries referral to emergency obstetric care is beset with problems such as difficult geographical terrain, transport costs, lack of vehicles, and suboptimal location and distribution of health care facilities. In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers assess the effectiveness of interventions designed to reduce the “phase II delay” in referral to emergency obstetric care in developing countries—the time it takes a woman to reach an appropriate health care facility once a problem has been recognized and the decision has been taken to seek care. Delays in diagnosis and the decision to seek care are phase I delays in referral, whereas delays in receiving care once a women reaches a health care facility are phase III delays.

What Did the Researchers Do and Find?

The researchers identified 19 published studies that described 14 interventions designed to overcome phase II delays in emergency obstetric referral and that met their criteria for inclusion in their systematic review. About half of the interventions were organizational. That is, they were designed to overcome barriers to referral such as costs. Most of the remaining interventions were structural. That is, they involved the provision of, for example, ambulances and maternity waiting homes—placed close to a health care facility where women can stay during late pregnancy. Although seven studies provided data on maternal mortality, none showed a sustained, statistically significant reduction (a reduction unlikely to have occurred by chance) in maternal deaths. Four studies in South Asia in which communities generated funds for transport reduced neonatal deaths (deaths of babies soon after birth), but the only statistically significant effect of this community mobilization intervention was seen in India where neonatal deaths were halved. Three studies from sub-Saharan Africa reported that the introduction of maternity waiting homes reduced stillbirths but this reduction was only significant in one study. Finally, although referral interventions generally improved the utilization of health services, in one study the provision of bicycle ambulances to take women to the hospital reduced the proportion of women delivering in health facilities, probably because women felt that bicycle ambulances drew unwanted attention to them during labor and so preferred to stay at home.

What Do These Findings Mean?

These findings suggest that community mobilization interventions may reduce neonatal mortality and that maternity waiting rooms may reduce stillbirths. Importantly, they also highlight how referral interventions can have unexpected adverse effects. However, because the studies included in this systematic review included multiple interventions designed to reduce delays at several stages of the referral process, it is not possible to disentangle the contribution of each component of the intervention. Moreover, it is impossible at present to determine why (or even if) any of the interventions reduced maternal mortality. Thus, the researchers conclude, improved monitoring of interventions and better evaluation of outcomes is essential to inform the implementation of effective referral interventions, and more studies are needed to improve understanding of how referral interventions work.

Additional Information

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001264.

The United Nations Children's Fund (UNICEF) provides information on maternal mortality, including the WHO/UNICEF./UNFPA/World Bank 2008 country estimates of maternal mortality
The World Health Organization provides information on maternal health, including information about Millennium Development Goal 5, which aims to reduce maternal mortality (in several languages); the Millennium Development Goals, which were agreed by world leaders in 2000, are designed to eradicate extreme poverty worldwide by 2015
Immpact is a global research initiative for the evaluation of safe motherhood intervention strategies
Veil of Tears contains personal stories from Afghanistan about loss in childbirth; the non-governmental health development organization AMREF provides personal stories about maternal health in Africa
Maternal Death: The Avoidable Crisis is a briefing paper published by Médecins Sans Frontières (MSF) in March 2012

INTERVENTIONS TO REDUCE NEONATAL MORTALITY FROM NEONATAL TETANUS IN LOW AND MIDDLE INCOME COUNTRIES - A SYSTEMATIC REVIEW

Adeel Ahmed Khan, Aysha Zahidie and Fauziah Rabbani

BMC Public Health 2013, 13:322 doi:10.1186/1471-2458-13-322

Published: 9 April 2013

Abstract (provisional)below; full text is at

http://www.biomedcentral.com/content/pdf/1471-2458-13-322.pdf

Background

In 1988, WHO estimated around 787,000 newborns deaths due to neonatal tetanus. Despite few success stories majority of the Low and Middle Income Countries (LMICs) are still struggling to reduce neonatal mortality due to neonatal tetanus. We conducted a systematic review to understand the interventions that have had a substantial effect on reducing neonatal mortality rate due to neonatal tetanus in LMICs and come up with feasible recommendations for decreasing neonatal tetanus in the Pakistani setting.

Methods

We systemically reviewed the published literature (Pubmed and Pubget databases) to identify appropriate interventions for reducing tetanus related neonatal mortality. A total of 26 out of 30 studies were shortlisted for preliminary screening after removing overlapping information. Key words used were "neonatal tetanus, neonatal mortality, tetanus toxoid women". Of these twenty-six studies, 20 were excluded. The pre-defined exclusion criteria was (i) did not have described the strategies and interventions to reduce mortality among neonates (8 studies) (ii) no abstract/author (4 studies) (iii) not freely accessible online (1 study) (iv) conducted in high income countries (2 studies) and (v) not directly related to neonatal tetanus mortality and tetanus toxoid immunization (5). Finally six studies which met the eligibility criteria were entered in the pre-designed data extraction form and five were selected for commentary as they were directly linked with neonatal tetanus reduction.

Result: Interventions that were identified to reduce neonatal mortality in LMICs were: a) vaccination of women of child bearing age (married and unmarried both) with tetanus toxoid b) community based interventions i.e. tetanus toxoid immunization for all mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; umbilical cord care and management of infections in newborns c) supplementary immunization (in addition to regular EPI program) d) safer delivery practices.

Conclusion

The key intervention to reduce neonatal mortality from neonatal tetanus was found to be vaccination of pregnant women with tetanus toxoid. In the resource poor countries like Pakistan, this single intervention coupled with regular effective antenatal checkups, clean delivery practices and compliance with the "high- risk" approach can be effective in reducing neonatal tetanus.

DISTANCE TO CARE, FACILITY DELIVERY AND EARLY NEONATAL MORTALITY IN MALAWI AND ZAMBIA

Terhi J. Lohela,

Affiliations: Department of Anaesthesiology and Intensive Care Medicine, Jorvi Hospital, Helsinki University Hospital, Espoo, Finland, University of Heidelberg, Institute of Public Health, Heidelberg, Germany

Oona M. R. Campbell,

Affiliation: London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom

Sabine Gabrysch mail

* E-mail: sabine.gabrysch@uni-heidelberg.de

Affiliation: University of Heidelberg, Institute of Public Health, Heidelberg, Germany

Abstract below; full text, with tables, is at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0052110

Background

Globally, approximately 3 million babies die annually within their first month. Access to adequate care at birth is needed to reduce newborn as well as maternal deaths. We explore the influence of distance to delivery care and of level of care on early neonatal mortality in rural Zambia and Malawi, the influence of distance (and level of care) on facility delivery, and the influence of facility delivery on early neonatal mortality.

Methods and Findings

National Health Facility Censuses were used to classify the level of obstetric care for 1131 Zambian and 446 Malawian delivery facilities. Straight-line distances to facilities were calculated for 3771 newborns in the 2007 Zambia DHS and 8842 newborns in the 2004 Malawi DHS. There was no association between distance to care and early neonatal mortality in Malawi (OR 0.97, 95%CI 0.58–1.60), while in Zambia, further distance (per 10 km) was associated with lower mortality (OR 0.55, 95%CI 0.35–0.87). The level of care provided in the closest facility showed no association with early neonatal mortality in either Malawi (OR 1.02, 95%CI 0.90–1.16) or Zambia (OR 1.02, 95%CI 0.82–1.26). In both countries, distance to care was strongly associated with facility use for delivery (Malawi: OR 0.35 per 10km, 95%CI 0.26–0.46). All results are adjusted for available confounders. Early neonatal mortality did not differ by frequency of facility delivery in the community.

Conclusions

While better geographic access and higher level of care were associated with more frequent facility delivery, there was no association with lower early neonatal mortality. This could be due to low quality of care for newborns at health facilities, but differential underreporting of early neonatal deaths in the DHS is an alternative explanation. Improved data sources are needed to monitor progress in the provision of obstetric and newborn care and its impact on mortality.

Citation: Lohela TJ, Campbell OMR, Gabrysch S (2012) Distance to Care, Facility Delivery and Early Neonatal Mortality in Malawi and Zambia. PLoS ONE 7(12): e52110. doi:10.1371/journal.pone.0052110

Editor: C. Mary Schooling, CUNY, United States of America

Received: April 17, 2012; Accepted: November 15, 2012; Published: December 27, 2012

Copyright: © 2012 Lohela et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: SG is paid by the University of Heidelberg through a Margarete von Wrangell Fellowship supported by the European Social Fund and by the Ministry of Science, Research and the Arts Baden-Württemberg, and has received salary support from the Medical Faculty’s Rahel Goitein-Straus Programme. TJL did this work as part of her MSc thesis and was subsequently employed by SG through Heidelberg University funds. OMRC is supported by the London School of Hygiene and Tropical Medicine. No funders had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.