Gunilla Lindmark

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study

BACKGROUND We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. METHODS In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. RESULTS From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). INTERPRETATION High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. FUNDING UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

Who continues to smoke while pregnant

STUDY OBJECTIVE--The aim was to study changes in smoking habits during pregnancy and differences in characteristics between women who stop smoking and those who continue to smoke during pregnancy. DESIGN--The study was a population based prospective study. Self administered questionnaires were completed on three occasions. SETTING--The study area was Uppsala county, Sweden, in 1987. PARTICIPANTS--The participants were women registered with antenatal care clinics, which included all pregnant women in the county. Ninety six percent (n = 3678) of all pregnant women completed the first questionnaire. Thirty two percent of these were smokers at time of conception. MEASUREMENTS AND MAIN RESULTS--Twenty nine percent of the smokers stopped smoking at some stage of pregnancy, and the majority did so before having registered for antenatal care. Using logistic regression analysis it was found that high parity number, not living with infants father, heavy smoking, and daily passive smoking at home were associated with significantly increased risk for continued smoking during pregnancy. High level of education and high age at onset of smoking decreased the risk. CONCLUSIONS--In order to reduce the smoking related risks for unsuccessful pregnancy outcome, general preventive efforts in society must be combined with the development of more specialised antenatal programmes designed with consideration of the characteristics and life situation of the pregnant smoker.

Randomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe

BACKGROUND Many of the individual components of antenatal care have been studied in randomised controlled trials, but few studies have compared whole programmes of antenatal care. Our aim was to test the hypothesis that a new programme of antenatal care with fewer goal-oriented visits would give an equivalent or better result in the outcomes associated with pregnancy and delivery. METHODS In a randomised clinical trial in Harare, Zimbabwe, we compared a new programme of antenatal care with the standard programme. The new programme consisted of fewer but more objectively oriented visits and fewer procedures per visit. Seven primary care clinics were randomly assigned to the two programmes-three to the standard programme and four to the new programme. FINDINGS Over a 2-year period, 15,994 women were recruited into the study at the time they booked antenatal care. 97% of the women were followed up, 9,394 who had followed the new programme, and 6,138 from clinics with the standard one. Women allocated to the new programme made, as planned, fewer visits than those in the standard programme (median 4 vs 6 visits, respectively). The proportion of antenatal referrals was also lower (13.6 vs 15.3%; odds ratio 0.87 [95% CI 0.79-0.95]) because of significantly fewer referrals for pregnancy-induced hypertension (2.5 vs 3.8%; 0.66 [0.55-0.79]). Nevertheless, there were significantly fewer labour referrals for severe hypertension or eclampsia (2.1 vs 2.6%; 0.81 [0.66-1.00]). The risk for preterm (< 37 weeks) delivery was significantly lower for women on the new programme (10.1 vs 11.5%; 0.86 [0.78-0.96]). There were no other significant differences between the programmes in other major indices of pregnancy outcome, including antenatal referrals for other causes, labour referrals, obstetric interventions, low birthweight, and perinatal and maternal mortality and morbidity. INTERPRETATION An antenatal care programme with fewer more objectively oriented visits can be introduced without adverse effects on the main intermediate outcome pregnancy variables.

Maternal morbidity and mortality associated with multiple gestations

Objective To test the hypothesis that women with multiple gestations are at increased risk of adverse maternal outcomes. Methods We studied the association between multiple gestation and frequency of adverse maternal outcomes in 885,338 pregnancies recorded in the Perinatal Information System database of the Latin American Center for Perinatology and Human Development, Montevideo, Uruguay, between 1985 and 1997. Relative risks (RRs) were adjusted for 14 potential confounding factors through multiple logistic regression models. Results There were 15,484 multiple gestations. Among parous women, multiple gestation was associated with a twofold increase in risk of death compared with singleton gestations [adjusted RR 2.1; 95% confidence interval (CI) 1.1, 3.9]. Compared with singleton gestations, women with multiple gestations had adjusted RRs of 3.0 (95% CI, 2.9, 3.3) for eclampsia, 2.2 (95% CI, 1.9, 2.5) for preeclampsia, and 2.0 (95% CI, 1.9, 2.0) for postpartum hemorrhage. Likewise, there was significant association between multiple gestation and increased incidence of preterm labor, anemia, urinary tract infection, puerperal endometritis, and cesarean delivery. The incidences of premature rupture of membranes, third-trimester bleeding, and gestational diabetes mellitus were not statistically different for singleton and multiple gestations. Conclusion Multiple gestation increases the risk of significant maternal morbidity and mortality.

Pre-pregnancy risk factors of small-for-gestational age births among parous women in Scandinavia

To study the etiology and consequences of intrauterine growth retardation (IUGR), a prospective study was organized by the National Institute of Child Health and Human Development, NIH, with the Universities of Trondheim and Bergen in Norway, Uppsala in Sweden, and Alabama in the United States. This paper reports on the Scandinavian portion of the study. 6,354 women were referred to the study and 5,722 women, who were expecting their second or third child between January 1986 and March 1988, were eligible and made their first appointment for the study. Of these, 1,945 women and their births were selected for follow‐up at four prenatal visits, delivery, and during the first year of life. This report analyzes the relative impact of various maternal pre‐pregnancy risk factors associated with SGA birth. For example, mothers who smoked cigarettes around the time of conception, but who had none of the other major risk factors, nearly doubled their risk of SGA birth. A previous low birth weight (LBW) delivery increased the risk nearly two and a half times among non‐smokers. If a mother both smoked and had a previous LBW, the relative risk rose to nearly five and a half. Low maternal pre‐pregnancy weight (> 50 kg) increased the risk of SGA birth almost twofold among non‐smokers, while low pre‐pregnancy weight and smoking together increased the risk of SGA birth fourfold. A low weight mother who smoked and also had a previous LBW delivery, had a risk of SGA birth that was nearly six times that of a mother without those characteristics.

Rural Tanzanian women's awareness of danger signs of obstetric complications

BackgroundAwareness of the danger signs of obstetric complications is the essential first step in accepting appropriate and timely referral to obstetric and newborn care. The objectives of this study were to assess womens awareness of danger signs of obstetric complications and to identify associated factors in a rural district in Tanzania.MethodsA total of 1118 women who had been pregnant in the past two years were interviewed. A list of medically recognized potentially life threatening obstetric signs was obtained from the responses given. Chi- square test was used to determine associations between categorical variables and multivariate logistic regression analysis was used to identify factors associated with awareness of obstetric danger signs.ResultsMore than 98% of the women attended antenatal care at least once. Half of the women knew at least one obstetric danger sign. The percentage of women who knew at least one danger sign during pregnancy was 26%, during delivery 23% and after delivery 40%. Few women knew three or more danger signs. According to multivariate logistic regression analysis having secondary education or more increased the likelihood of awareness of obstetric danger signs six-fold (OR = 5.8; 95% CI: 1.8–19) in comparison with no education at all. The likelihood to have more awareness increased significantly by increasing age of the mother, number of deliveries, number of antenatal visits, whether the delivery took place at a health institution and whether the mother was informed of having a risks/complications during antenatal care.ConclusionWomen had low awareness of danger signs of obstetric complications. We recommend the following in order to increase awareness of danger signs of obstetrical complications: to improve quality of counseling and involving other family members in antenatal and postnatal care, to use radio messages and educational sessions targeting the whole community and to intensify provision of formal education as emphasized in the second millennium development goal.

Physical symptoms after childbirth: prevalence and associations with self‐rated health

Objective  The aims of the present study were to describe the prevalence of a number of physical symptoms, as described by women themselves, two months and one year after childbirth in a national Swedish sample and to investigate the association between specific symptoms and womens self‐rated health.

The scientific basis of antenatal care: Report from a state‐of‐the‐art conference*

The routine program for antenatal care consists of a number of scheduled visits aiming at detection of symptomless complications such as hypertension and deviation in fetal growth, as well as giving psychosocial support and health education. In a Swedish state‐of‐the‐art conference in May 1990, the scientific basis of this routine program was critically evaluated. It was clearly demonstrated that the scientific evidence to support present timing and contents of routine visits is unsatisfactory, and that there is a great need for evaluation both of single diagnostic procedures and intervention and of programs of antenatal care. Evaluations of antenatal care should consider not only pregnancy outcome but also patient satisfaction and cost‐benefit analysis. Long‐term follow‐up studies are urgently needed, not only of the effects of complications but also of antenatal diagnosis and interventions.

Symptoms of stress incontinence 1 year after childbirth: prevalence and predictors in a national Swedish sample

Background.  The aims of the present study were to describe the prevalence of stress incontinence, as described by women themselves, 1 year after childbirth in a national sample of Swedish‐speaking women, and to identify possible predictors.

Early and Late Discharge after Hospital Birth: Breastfeeding

Breastfeeding was studied among women discharged early and late after normal delivery in a hospital. Early discharge was defined as leaving the hospital 24–48 h after delivery in combination with domiciliary visits, and late discharge as the regular hospital postpartum care (mean 6 days). 164 women interested in participating in the early discharge study were randomly allocated in late pregnancy to a group offered early discharge (Experimental group = EG) or a group offered the traditional later discharge (Control group = CG). After medical exclusions and non‐medical withdrawals, 50 mother‐infant couples remained in EG and 54 in CG. Regular breastfeeding at 6 months after birth was reported by 63% of the multiparae in EG and 41% in CG (p=0.06). Thirty‐three per cent of the primiparae in each group were still breastfeeding at 6 months. 2% of the infants in EG and 72% in CG received supplementary breastmilk at least once during their first week of life. Infants discharged early were breastfed more often on the 2nd (NS), 3rd (p<0.05) and 4th day (p<0.001) after birth, compared with infants who stayed longer in hospital. There were no statistically significant differences between EG and CG women in their experiences of success in breastfeeding according to daily records from the first 14 days after the birth.