Amie Wilson

Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis

BACKGROUND Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of womens groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings. METHODS We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of womens groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the womens group intervention and estimated its potential effect at scale in Countdown countries. FINDINGS Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to womens groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries. INTERPRETATION With the participation of at least a third of pregnant women and adequate population coverage, womens groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. FUNDING Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis

Objective To assess the effectiveness of strategies incorporating training and support of traditional birth attendants on the outcomes of perinatal, neonatal, and maternal death in developing countries. Design Systematic review with meta-analysis. Data sources Medline, Embase, the Allied and Complementary Medicine database, British Nursing Index, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, BioMed Central, PsycINFO, Latin American and Caribbean Health Sciences Literature database, African Index Medicus, Web of Science, Reproductive Health Library, and Science Citation Index (from inception to April 2011), without language restrictions. Search terms were “birth attend*”, “traditional midwife”, “lay birth attendant”, “dais”, and “comadronas”. Review methods We selected randomised and non-randomised controlled studies with outcomes of perinatal, neonatal, and maternal mortality. Two independent reviewers undertook data extraction. We pooled relative risks separately for the randomised and non-randomised controlled studies, using a random effects model. Results We identified six cluster randomised controlled trials (n=138 549) and seven non-randomised controlled studies (n=72 225) that investigated strategies incorporating training and support of traditional birth attendants. All six randomised controlled trials found a reduction in adverse perinatal outcomes; our meta-analysis showed significant reductions in perinatal death (relative risk 0.76, 95% confidence interval 0.64 to 0.88, P<0.001; number needed to treat 35, 24 to 70) and neonatal death (0.79, 0.69 to 0.88, P<0.001; 98, 66 to 170). Meta-analysis of the non-randomised studies also showed a significant reduction in perinatal mortality (0.70, 0.57 to 0.84, p<0.001; 48, 32 to 96) and neonatal mortality (0.61, 0.48 to 0.75, P<0.001; 96, 65 to 168). Six studies reported on maternal mortality and our meta-analysis showed a non-significant reduction (three randomised trials, relative risk 0.79, 0.53 to 1.05, P=0.12; three non-randomised studies, 0.80, 0.44 to 1.15, P=0.26). Conclusion Perinatal and neonatal deaths are significantly reduced with strategies incorporating training and support of traditional birth attendants.

A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies

Objective To review the effectiveness and safety of clinical officers (healthcare providers trained to perform tasks usually undertaken by doctors) carrying out caesarean section in developing countries compared with doctors. Design Systematic review with meta-analysis. Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, the Reproductive Health Library, and the Science Citation Index (inception-2010) without language restriction. Study selection Controlled studies. Data extraction Information was extracted from each selected article on study characteristics, quality, and outcome data. Two independent reviewers extracted data. Results Six non-randomised controlled studies (16 018 women) evaluated the effectiveness of clinical officers carrying out caesarean section. Meta-analysis found no significant differences between the clinical officers and doctors for maternal death (odds ratio 1.46, 95% confidence interval 0.78 to 2.75; P=0.24) or for perinatal death (1.31, 0.87 to 1.95; P=0.19). The results were heterogeneous, with some studies reporting a higher incidence of both outcomes with clinical officers. Clinical officers were associated with a higher incidence of wound infection (1.58, 1.01 to 2.47; P=0.05) and wound dehiscence (1.89, 1.21 to 2.95; P=0.005). Two studies accounted for confounding factors. Conclusion Clinical officers and doctors did not differ significantly in key outcomes for caesarean section, but the conclusions are tentative owing to the non-randomised nature of the studies. The increase in wound infection and dehiscence may highlight a particular training need for clinical officers.

“If it helps …” the use of microarray technology in prenatal testing: Patient and partners reflections

The objective was to gain insight into the experiences of women and their partners diagnosed with a fetal abnormality on prenatal ultrasound examination and receiving genetic testing including microarray. Twenty‐five semi‐structured interviews were performed with women +/− their partners after receiving the results of prenatal genetic testing. Framework analysis was performed to elicit themes and subthemes. Five main themes were recognized; diagnosis, genetic testing, family and support, reflections of the treatment received and emotions. Our results showed that women recall being told about QFPCR for trisomy 13, 18, and 21 but often no further testing. Women expected the conventional karyotype and microarray result would be normal following a normal QFPCR result. There were frequent misconceptions by couples regarding aspects of counseling/testing. Communication of variants of unknown (clinical) significance (VOUS) presents a particularly difficult challenge. Good clear communication by health care professionals is paramount. When counseling women and their partners for fetal chromosomal testing it should be reinforced that although the most common, trisomy 13, 18, and 21 only account for some of the chromosomal changes resulting in abnormal scan findings. Couples should have literature to take home summarizing scan anomalies and reinforcing information about genetic testing.

A systematic review and thematic synthesis of qualitative studies on maternal emergency transport in low- and middle-income countries

Most maternal deaths are preventable with emergency obstetric care; therefore, ensuring access is essential. There is little focused information on emergency transport of pregnant women.

Symphysiotomy for obstructed labour: a systematic review and meta-analysis.

Obstructed labour is a major cause of maternal mortality. Caesarean section can be associated with risks, particularly in low‐ and middle‐income countries, where it is not always readily available. Symphysiotomy can be an alternative treatment for obstructed labour and requires fewer resources. However, there is uncertainty about the safety and effectiveness of this procedure.

Resource availability for the management of maternal sepsis in Malawi, other low-income countries, and lower-middle-income countries

To assess the availability of key resources for the management of maternal sepsis and evaluate the feasibility of implementing the Surviving Sepsis Campaign (SSC) recommendations in Malawi and other low‐resource settings.

Author's reply re: Symphysiotomy for obstructed labour: a systematic review and meta‐analysis

We would like to thank D. A. A Verkuyl for the response to our recent paper; ‘Symphysiotomy for obstructed labour: a systematic review and meta-analysis’. We indeed agree that the published studies have the risk of underestimating the complications associated with the intention to perform a caesarean section, as lucidly laid out by Verkuyl. We believe that there are circumstances when we should consider symphysiotomy as a therapeutic option. We appreciate that none of the studies within the review was randomised, and therefore the effects of selection bias cannot be ruled out. However, any potential bias of selection could be in either direction, i.e. it is possible that the more extreme cases underwent caesarean section or symphysiotomy. In the absence of randomised evidence, our review provides the best evidence and it shows that symphysiotomy may not be more harmful than caesarean section. We believe that symphysiotomy should be considered as an option, especially where effective, safe and timely access to caesarean section is limited. Even if this evidence does not influence practice, there is at least, as a minimum, the need to generate further credible evidence.&

A Comparison of Clinical Officers With Medical Doctors on Outcomes of Cesarean Section in the Developing World: Meta-analysis of Controlled Studies

Because many developing countries have too few trained doctors, clinical officers, that is, health care providers trained to perform tasks usually done by doctors, are increasingly performing cesarean sections. Their training is different from that of medical doctors, but they perform anesthesia, diagnose and treat medical conditions, and prescribe medications. Their scope of practice within obstetrics is frequently determined by the country in which they work, and although they may be allowed to provide obstetric care, often they are not permitted to perform cesarean section or other emergency obstetric surgery. Because cesarean section is the most common major surgical procedure in sub-Saharan Africa, clinical officers can have an important part in making emergency obstetric care accessible and available to women in this region of the world. However, their effectiveness and safety are uncertain. This systematic review with meta-analysis examined the effectiveness and safety of clinical officers performing cesarean section. Medline, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, the Reproductive Health Library, and the Science Citation Index were searched for controlled studies without language restriction. The controlled studies had to compare clinical officers and medically trained doctors performing cesarean section in the developing world and had to report on clinically relevant maternal or perinatal outcomes. A total of 7687 citations were identified from electronic searches, of which 7634 were excluded. The investigators performed detailed evaluations of 65 articles, 53 from the electronic search and 12 from the reference lists of articles found electronically. Of these, 59 were excluded for unavailable outcomes, noncontrolled studies, or inappropriate populations. Therefore, the review included 6 nonrandomized-controlled cohort studies involving 16,018 women. Methodological quality, assessed by the NewcastleOttawa scale, showed that most studies had a medium risk for selection bias and medium-to-high risk for comparability of cohorts and outcome assessment. Meta-analysis showed no statistically significant difference between the clinical officers and doctors in maternal mortality [odds ratio (OR) 1.46, all 6 studies] or perinatal mortality (OR 1.31, 5 of 6 studies). The overall maternal mortality rate in the 6 studies and the perinatal mortality rate reported in 5 studies were 1.2% and 10.7%, respectively. There was significant heterogeneity among studies. The 2 studies that compared the rates of wound infection showed a significant increase when clinical officers performed the surgery (OR 1.58). Wound dehiscence was compared in 3 studies, and a significant increase in this complication was found when clinical officers performed the cesarean section compared with doctors (OR 1.89). All 6 studies gave details of the clinical officers’ training. Length and specifications of training varied among countries although most received 2 to 3 years of general medical training and 6 months—2 years of surgical training. Because the studies assessed were not randomized, the results of this meta-analysis should be considered preliminary. However, the authors did conclude that greater use of clinical officers to provide obstetric care and perform cesarean section in countries with poor availability of medical doctors could assist with meeting Millennium Development Goals 4 and 5 (reducing child mortality and improving maternal health, respectively).