Frank W.J. Anderson

Complementary and alternative medicine in obstetrics

To identify, survey and review randomized controlled studies of the use of complementary and alternative medicine (CAM) for obstetric treatment or health promotion.

Maternal Mortality and the Consequences on Infant and Child Survival in Rural Haiti

AbstractObjective: To determine the odds of death of children when a woman of reproductive age dies from maternal or non maternal causes in rural Haiti. Methods: Deaths among reproductive aged women between 1997 and 1999 in and around Jeremie, Haiti were classified as maternal or non maternal and matched to female, non-deceasesd controls based on village, age, and parity. Information regarding the health and survival of all of the offspring under 12 years old of the identified women was extracted from the Haitian Health Foundation (HHF) Health Information System (HIS). Additional demographic information was obtained through interviews with the mothers for controls and with family members for cases. Two analyses on child death were conducted; 1) the odds of death for each individual child after a mother’s death and 2) the odds of one of the children in a family dying after the mother’s death. Findings: If a family experiences a maternal death, that family has a 55.0% increased odds of experiencing the loss of a child less than 12, whereas when a non maternal death occurs, no increased odds exists. When children of cases were compared to children of controls, mean weight z-scores were the same for the periods corresponding to before and after the maternal deaths. After a maternal death, dosage of BCG (Bacillus Calmette-Guerin) TB (tuberculosis) immunization for the surviving child is significantly lower, as are dosage of measles immunization and the first dose of vitamin A. Conclusions: This study shows that a maternal death significantly effects the survival of children in a family in a greater way than a non maternal death.

Association of maternal sleep practices with pre-eclampsia low birth weight and stillbirth among Ghanaian women.

To assess sleep practices, and investigate their relationship with maternal and fetal outcomes, among pregnant Ghanaian women.

Sudden death: ectopic pregnancy mortality.

OBJECTIVE: To describe the trends in ectopic pregnancy mortality in Michigan from 1985 through 1999 and compare to those of previous time periods. METHODS: We reviewed all cases of maternal mortality from ectopic pregnancy in Michigan from 1985 through 1999. We extracted data from death certificates, hospital inpatient and emergency department records, medical examiner autopsy reports, and reviews by the Michigan Maternal Mortality Study. The Health Data Development Section of the Michigan Department of Community Health provided data on live births and maternal deaths RESULTS: Of the 268 pregnancy-related deaths, 16 (6%) were caused by complications of ectopic pregnancy. Mean age at death was 27 (± 6) years. Thirteen deaths were to African-American women and 3 were to white women (P < .01). African-American women had an ectopic mortality ratio 18 times higher than white women (3.25/100,000 live births, compared with 0.18/100,000) Three cases of pregnancy-related death due to complications of ectopic pregnancy were considered preventable, and 2 others were of unknown preventability. CONCLUSION: Ectopic pregnancy treatment has changed in the last 20 years coincident with a decrease in maternal mortality from ectopic pregnancy. Sudden death was the presenting scenario in 75% of nonpreventable ectopic deaths, an increase from previous analyses. A large racial disparity is apparent. Ideally, pregnancy care should start as soon as possible after the first missed menses; however, systemwide changes are needed to create a new norm promoting early access to pregnancy care and promoting education and testing to rule out pregnancy abnormalities. LEVEL OF EVIDENCE: II-2

Obstetric fistula in low-income countries

To identify, survey, and systematically review the current knowledge regarding obstetric fistula as a public health problem in low‐income countries from the peer‐reviewed literature.

QUALITY OF LIFE, OPTIMISM/PESSIMISM, AND KNOWLEDGE AND ATTITUDES TOWARD HIV SCREENING AMONG PREGNANT WOMEN IN GHANA

OBJECTIVE We sought to explore optimism/pessimism, knowledge of HIV, and attitudes toward HIV screening and treatment among Ghanaian pregnant women. METHOD Pregnant women in Accra, Ghana, completed a self-administered questionnaire including the Life Orientation Test-Revised (LOT-R, an optimism/pessimism measure), an HIV knowledge and screening attitudes questionnaire, the Short Form 12 (SF-12, a measure of health-related quality of life [HRQOL]), and a demographic questionnaire. Data were analyzed using t-tests, ANOVA, correlations, and the chi2 test. RESULTS There were 101 participants; 28% were nulliparous. Mean age was 29.7 years, and mean week of gestation was 31.8. All women had heard of AIDS, 27.7% had been tested for HIV before this pregnancy, 46.5% had been tested during this pregnancy, and 59.4% of the sample had ever been tested for HIV. Of those not tested during this pregnancy, 64.2% were willing to be tested. Of all respondents, 89% said they would get tested if antiretroviral drugs (ARVs) were readily available and might prevent maternal-to-child transmission. Neither optimism/pessimism nor HRQOL was associated with attitudes toward HIV screening. Optimism was negatively correlated with HIV knowledge (p = .001) and was positively correlated with having never been tested before this pregnancy (p = .007). CONCLUSION The relationship between optimism/pessimism and HIV knowledge and screening behavior is worthy of further study using larger samples and objective measures of testing beyond self-report.

The Public Health Impact of Training Physicians to Become Obstetricians and Gynecologists in Ghana

OBJECTIVES We assessed the public health effect of creating and sustaining obstetrics and gynecology postgraduate training in Ghana, established in 1989 to reverse low repatriation of physicians trained abroad. METHODS All 85 certified graduates of 2 Ghanaian university-based postgraduate training programs from program initiation in 1989 through June 2010 were identified and eligible for this study. Of these, 7 were unable to be contacted, inaccessible, declined participation, or deceased. RESULTS Of the graduates, 83 provide clinical services in Ghana and work in 33 sites in 8 of 10 regions; 15% were the first obstetrician and gynecologist at their facility, 25% hold clinical leadership positions, 50% practice in teaching hospitals, and 14% serve as academic faculty. CONCLUSIONS Creating capacity for university-based postgraduate training in obstetrics and gynecology is effective and sustainable for a comprehensive global approach to reduce maternal and neonatal morbidity and mortality. Policies to support training and research capacity in obstetrics and gynecology are an integral part of a long-term national plan for maternal health.

Maternal Mortality: An Enduring Epidemic

Women continue to die from pregnancy-related causes at an alarming rate. Maternal mortality was first called a neglected epidemic in 1985, but to date, no significant improvements have been realized. Great disparity exists as lifetime risk of dying from pregnancy is 1 in 26 in Africa, 1 in 7300 in high-income areas. The UN Millennium Development Goals call for a 75% reduction in maternal mortality by 2015, which will only be realized when priority setting, funding, and program implementation can create conditions for appropriate human resources, infrastructure, and patient education for high-quality obstetric care.

A Low-Cost Simulator for Learning to Manage Postpartum Hemorrhage in Rural Africa

Introduction: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Africa and Asia. Despite an UN Millennium Development Goal to reduce maternal mortality rates, no significant effect has resulted to date, in large part because women in these areas give birth in rural communities with poor access to definitive care. Traditional birth attendants (TBAs) provide care for delivering mothers; however, they are neither trained nor equipped to recognize or manage PPH as a life-threatening emergent condition. The purpose of this study was to design and evaluate a low-cost, portable simulator for training TBAs and nurse midwives in the use of bimanual compression to manage PPH. Methods: Clinicians in USA and Ghana were consulted to develop the engineering specifications, including low cost, long lifetime, easy to use, portable, and high anatomic and procedural fidelity. Pugh charts were used to finalize the design from multiple concepts. The simulator was built and evaluated for validity by American and Ghanaian obstetricians, nurse midwives, midwifery students, and TBAs. The feasibility of the simulator for training illiterate learners was also assessed. Results: The simulator was evaluated to be an effective training platform with excellent fidelity and valid feedback mechanisms. It was demonstrated to be a feasible platform for training illiterate TBAs to perform bimanual compression. Conclusions: The low cost, portable simulator developed for this project has the potential to reduce maternal mortality from PPH in the developing world. Research is ongoing in this application.

Maternal Deaths Due to Sepsis in the State of Michigan, 1999–2006

OBJECTIVE: To identify maternal deaths due to sepsis in the state of Michigan, review the events leading to diagnosis, and evaluate treatment to identify areas for improvement. METHODS: A case series was collected for maternal deaths due to sepsis from a cohort of maternal deaths in the state of Michigan. The study period was 1999–2006 and included deaths during pregnancy and up to 42 days postpartum. Cases were identified using Maternal Mortality Surveillance records from the Michigan Department of Community Health. Each case was reviewed by all authors. RESULTS: Maternal sepsis was the cause of death in 15% (22/151) of pregnancy-related deaths. Of 22 deaths, 13 women presented to the hospital with sepsis, two developed sepsis during hospitalization, and seven developed sepsis at home without admission to the hospital for care. Review of available hospital records (n=15) revealed delays in initial appropriate antibiotic treatment occurred in 73% (11/15) of patients. Delay in escalation of care also occurred and was identified in 53% (8/15) of patients. CONCLUSION: Common elements in these deaths illustrate three key delays that may have contributed to the deaths: in recognition of sepsis, in administration of appropriate antibiotics, and in escalation of care. LEVEL OF EVIDENCE: III