Anne Paxton

The evidence for emergency obstetric care

We searched for evidence for the effectiveness of emergency obstetric care (EmOC) interventions in reducing maternal mortality primarily in developing countries.

Maternal Reporting of Prepregnancy Weight and Birth Outcome: Consistency and Completeness Compared with the Clinical Record

Objectives: We examined whether data obtained by maternal report could be used for research in clinical settings in place of abstraction of the clinical record. Method: Reported prepregnancy weight, delivery type, and infants birth date, birth weight, and length were compared to the same information from the clinical record. Results: Reported data, obtained from 198 women, were more complete than data in the 168 clinical records obtained. Prepregnancy weight from the clinical record was highly correlated with weight measured by us in early pregnancy, and with the value reported by the mother (differing significantly only in underweight women, who overreported by 2.4 lbs). There was complete concordance on birth date and method of delivery, and no significant differences in mean birth weight or length, between the reported and recorded information. Conclusion: The mothers report is a satisfactory substitute for clinical record data, being consistent with the record, and more complete, yet easier to obtain for clinical studies.

Global patterns in availability of emergency obstetric care.

Objective: This paper examines the availability of basic and comprehensive emergency obstetric care (EmOC), interventions used to treat direct obstetric complications. Determining what interventions are provided in health facilities is the first priority in analyzing a countrys capabilities to treat obstetric emergencies. There are eight key interventions, six constitute basic EmOC and all eight comprehensive EmOC. Methods and results: Based on data from 24 needs assessments, the following global patterns emerge: comprehensive EmOC facilities are usually available to meet the recommended minimum number for the size of the population, basic EmOC facilities are consistently not available in sufficient numbers, both in countries with high and moderate levels of maternal mortality, and the majority of facilities offering maternity services provide only some interventions indicating an unrealized potential. Conclusion: Upgrading maternities, health centers and hospitals to at least basic EmOC status would be a major contributing step towards maternal mortality reduction in resource‐poor countries.

Body fat and water changes during pregnancy in women with different body weight and weight gain

Objective To determine the fat deposited during pregnancy in women gaining according to recommendations of the Institute of Medicine and the relationship of weight gain to fat gain in women of different starting weights (classified by their body mass index). Methods A cohort study of healthy, nonsmoking women, 18–36 years of age, identified during prenatal visits at three hospital clinics and one birthing center in New York City. From a pool of 432 eligible volunteers who signed a consent form, body composition measurements were performed on 200 women at weeks 14 (−2) and 37+ of pregnancy, and bone mineral mass was measured at 2–4 weeks postpartum. Body fat was estimated with a model that used total body water, weight, and density and bone mineral mass. Results In women gaining as recommended by the Institute of Medicine, fat gains during pregnancy for women underweight, normal weight, overweight, or obese before pregnancy were 6.0 ± 2.6 kg, 3.8 ± 3.4 kg, 3.5 ± 4.1 kg, and −0.6 ± 4.6 kg, respectively. Higher weight gain increased fat gain. Body water gain was not different among the four prepregnancy weight groups. Conclusion Recommended weight gain should not cause obesity in any weight group. Underweight women will normalize their body composition if they gain as recommended, whereas obese women will have little or no change in body fat. A majority of women do not gain as recommended during pregnancy.

The United Nations Process Indicators for emergency obstetric care: Reflections based on a decade of experience

Objective: The paper reviews the experience with the EmOC process indicators, and evaluates whether the indicators serve the purposes for which they were originally created – to gather and interpret relatively accessible data to design and implement EmOC service programs.

The availability of life-saving obstetric services in developing countries: An in-depth look at the signal functions for emergency obstetric care.

Objective: This paper examines the frequency with which a set of life‐saving interventions or signal functions was performed to treat major obstetric complications. Methods and results: The basic signal functions include parenteral antibiotics, anticonvulsants and oxytocics, and the procedures of manual removal of the placenta, removal of retained uterine products, and assisted vaginal delivery. Comprehensive functions include the six basic functions, cesarean delivery, and blood transfusions. Data from 1906 health facilities in 13 countries indicate that the most likely functions to be reported are oxytocics and antibiotics. The basic function least likely to be reported is assisted vaginal delivery. Many of the facilities surveyed did not have the infrastructure to perform operations or provide blood transfusions. Conclusions: These data can help governments allocate their budgets appropriately, help policy makers and planners identify systemic bottlenecks and prioritize solutions. Monitoring the performance of the functions informs us of the capacity of the health system to provide key interventions when obstetric emergencies occur.

Program note. Using UN process indicators to assess needs in emergency obstetric services.

The UN process indicators have been recognized as a tool to identify the availability use and the quality of emergency obstetric care (EmOC). To improve access to EmOC the Averting Maternal Death and Disability (AMDD) Program was established in 1999. This paper describes the baseline indicators collected in three country projects of Mozambique Nepal and Senegal. These indicators include: number of facilities providing emergency obstetric functions; proportion of women who deliver at EmOC facilities; met need; cesarean deliveries as a proportion of all births; and case fatality rate. These point out key problems of the program and help managers of Safe Motherhood programs prioritize their activities. During the course of the AMDD Program the process indicators will be estimated periodically to monitor progress of program actions.

Does clinical diagnosis indicate ocular chlamydial infection in areas with a low prevalence of trachoma

The WHO has initiated a global program to eliminate trachoma. This program includes mass antibiotic administrations to reduce the prevalence of Chlamydia trachomatis, the causative agent in trachoma. DNA amplification tests are the most sensitive methods to diagnose C. trachomatis infection, but are expensive and not typically performed in trachoma-endemic areas. Trachoma programs use clinical examination to determine which communities and which individuals within communities would benefit from antibiotic treatment, so understanding the relationship between clinical activity and chlamydial infection is important. In this study, we determine what percent of individuals with clinically active trachoma are infected with chlamydia in low prevalence communities of China and Nepal (with <10% clinical activity in children), and compare this against a high prevalence community of Nepal (with >30% clinical activity in children). In the low prevalence areas, only 8% clinically active cases had evidence of chlamydia. In the high prevalence community, 70% of clinically active cases harbored chlamydia. These results imply that clinical activity is less indicative of infection at a lower prevalence. In the context of a trachoma program, both clinically active cases and the community as a whole may stand to benefit less from antibiotic treatment in lower prevalence areas.

Program note: Using UN process indicators to assessneeds in emergency obstetric services: Morocco, Nicaragua and Sri Lanka

The indicators are also useful at monitoring changes in availability, utilization and quality. The definitions are summarized in Table 1 and recommended levels can be found in the results tables. The UN indicators developed from an understanding that certain medical services or procedures are necessary to save the lives of women with obstetric complications. These procedures or ‘signal functions’ distinguish facilities that provide

Rapid assessment of trachoma in Hainan Province, China: validation of the new World Health Organization methodology.

This study was undertaken to validate a WHO methodology for the rapid assessment of trachoma. Fourteen villages were chosen by random sampling in two counties in Hainan Province, China. For the rapid assessment, trichiasis patients were identified, 50 children ages 1–10 years were examined for active trachoma, and information was collected on community access to services and community risk factors. To validate the methodology, a prevalence survey was undertaken simultaneously in the same villages. For the prevalence survey, 2428 people from 1606 households in the 14 villages were chosen by random sampling. Very little active trachoma was found by either method, although the rates of trichiasis were more substantial. Ranking of the villages by the two methods for trichiasis was highly corre-lated (Spearmans correlation coefficient = 0.60, p = 0.02). For active trachoma, the Spearmans correlation coefficient for the ranking of villages by the two methods was 0.40 and not significant (p = 0.14), suggesting that a correlation this close may have been seen by chance alone. The observational data showed all the villages to be at risk of active trachoma (due to poor environmental hygiene conditions), suggesting that this aspect of the WHO methodology overestimates the risk for active trachoma. We conclude that, with the exception of the community assessment of risk, this rapid assessment methodology is a valid tool for the assessment of trichiasis and possibly of active trachoma in rural communities, although the level of active trachoma in this study was too low to effectively validate that aspect of the methodology.