Khalid Yunis

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.

Household crowding index: a correlate of socioeconomic status and inter-pregnancy spacing in an urban setting

Objectives: This paper examines the effect of household crowding on inter-pregnancy spacing and its association with socioeconomic indicators, among parous mothers delivered in an urban environment. Design: Cross sectional survey. Methods: Sociodemographic data were obtained on 2466 parous women delivering at eight hospitals in Greater Beirut over a one year period. Statistical methodology comprised Pearson χ2 test and logistic regression analysis. Main results: A significant inverse relation was observed between household crowding and socioeconomic status, defined as education and occupation of women and their spouses. Inter-pregnancy spacing increased with higher levels of crowding. Further analysis suggested that this positive association was confounded by maternal demographic characteristics. Conclusions: These data have shown that household crowding, a correlate of low parental socioeconomic status, is associated with longer birth intervals. This association, however, seems to be largely explained by maternal age and parity.

Effect of narghile and cigarette smoking on newborn birthweight

Objective  To assess the effect of narghile smoking on the weight of newborns.

Predictors of breast-feeding in a developing country: results of a prospective cohort study

OBJECTIVE Data on the prevalence and predictors of breast-feeding remain scarce in Lebanon. Moreover, no study has previously addressed the effect of the paediatricians sex on breast-feeding. The present study aimed to assess the prevalence and predictors of breast-feeding at 1 and 4 months of infant age while exploring the potential role of the sex of the paediatrician. DESIGN Prospective cohort study. Predictors of breast-feeding significant at the bivariate level were tested at 1 and 4 months through two stepwise regression models. SETTING Infants were enrolled through the clinics and dispensaries of 117 paediatricians located in Beirut, Lebanon, and its suburbs. SUBJECTS A total of 1,320 healthy newborn infants born between August 2001 and February 2002 were prospectively followed during the first year. FINDINGS Breast-feeding rates at 1 and 4 months were 56.3 % and 24.7 %, respectively. Early discharge, high parity and religion were significantly associated with higher breast-feeding rates at 1 and 4 months of age. Maternal age proved significant only at 1 month, while maternal working status and sex of the paediatrician were significant at 4 months. A novel finding of our study was the positive effect of female paediatricians on breast-feeding continuation until 4 months of age (OR = 1.49; 95 % CI 1.03, 2.15). CONCLUSIONS Breast-feeding rates are low at 1 and 4 months of infant age in Beirut. Further research to investigate the interactions between female physicians and lactating mothers in maintaining breast-feeding in other populations is warranted. The results constitute the basis for designing interventions targeting policy makers, health professionals and mothers.

Bone mineralization in newborns whose mothers received magnesium sulphate for tocolysis of premature labour.

Prolonged maternal magnesium sulphate infusion therapy for tocolysis of premature labour may result in secondary fetal hypermagnesaemia, which has been associated with bony abnormalities in the newborn. We report on four infants, members of two twin pregnancies, who were exposed to prolonged fetal hypermagnesaemia. Three of the infants, all appropriate for gestational age, showed abnormal radiological findings consisting of abnormal mineralisation of long-bone metaphyses owing to fetal hypermagnesaemia. The fourth infant, who was growth retarded, had normal bones. Intrauterine growth restriction appears to be protective against magnesium sulphate-induced abnormal bone mineralisation in the newborn.

Development of criteria for identifying neonatal near-miss cases: analysis of two WHO multicountry cross-sectional studies.

To develop and test markers of neonatal severe morbidity for the identification of neonatal near‐miss cases.

Methotrexate embryopathy after therapy for misdiagnosed ectopic pregnancy

ase, alanine aminotransferase, and lactic dehydrogenaselevels are slightly elevated even in patients with severejaundice, which differentiates it from viral hepatitis. Adefinite diagnosis is made on either isolation of the organismfrom the patient’s urine, blood, or cerebrospinal fluid, or byserologic specific test. In severe cases a pulmonary radio-graphmayshowapatchy alveolarpattern. Treatmentdetailsare given in Table 1.Carles et al. [2] reported 11 cases from French Guyana inwhich fetal loss or death occurred in 50%. Chedraui and SanMiguel [3] reported a case of leptospirosis at 28 weeks ofpregnancy successfully treated with penicillin G, whichresulted in live birth at term. Baytur et al. [4] reported apregnancy complicated by Weil’s disease that resultedin preterm delivery with fetal loss; the mother receivedmeropenem and recovered completely.Leptospirosis may not be an uncommon cause of perinataldeaths in endemic areas. To implement effective treatmentfor successful pregnancy outcome, a high index of suspicionand early diagnosis is important.

Mutational spectrum of cystic fibrosis in the Lebanese population

BACKGROUND Cystic fibrosis (CF) is the most common autosomal recessive disease in Caucasians; it is however, considered to be rare in the Arab populations. Reports of the cystic fibrosis transmembrane regulator (CFTR) mutations from Arabs, especially from the Lebanese population, are limited. METHODS Twenty-two unrelated Lebanese families, with at least one child with CF, were studied. DNA extracts from blood samples of patients and parents were screened for CFTR gene mutations. RESULTS Eleven different mutations were identified. Of the 44 alleles studied, the most common mutations were: F508del (34%), N1303K (27%), W1282X (7%), and S4X (7%). Five mutations - not previously reported in the Lebanese population - were identified; these are: S549N, G542X, 2043delG, 4016insG, and R117H-7T. CONCLUSIONS The most common CFTR mutations in addition to five mutations not previously described in the Lebanese population were identified. Identification of CFTR mutations in the Lebanese population is important for molecular investigations and genetic counseling.

Prenatal and neonatal Group B Streptococcus screening and serotyping in Lebanon: incidence and implications

The study aimed at determining the prevalence, risk factors, perinatal transmission, and serotypes of Group B Streptococcus (GBS) among pregnant women and their newborns in Beirut, Lebanon. This was a cross‐sectional study of all pregnant women admitted from February to September 2006 to three major hospitals. Overall, 137 of 775 (17.7%) mothers and 50 of 682 newborns (7.3%) tested positive for GBS. Maternal colonization was not associated with maternal age, household income, gravidity, intrapartum fever, preterm labor, or premature rupture of membrane. Transmission rate was 40/120 (30%). Serotype 5 (24.1%) was the most common followed by serotype 1a (15.0%), 3 (14.4%), 2 (11.8%) and 1b (7.5%). Pregnant women in Lebanon appear to have a relatively high prevalence of GBS colonization with no identifiable risk factors for its acquisition. These results could provide basis for the institution of a national policy for universal maternal GBS screening to reduce neonatal morbidity and mortality.

Low socioeconomic status and neonatal outcomes in an urban population in a developing country

Objective: To investigate the effect of low socioeconomic status indicators, specifically parental educational and occupational characteristics on neonatal health outcomes. Methods: Analysis of 3372 newborn infants admitted to five National Collaborative Perinatal Neonatal Network centers (1 February 2000 to 31 January 2002). Outcomes included birth weight, gestational age, admission to the neonatal intensive care unit (NICU) and length of hospital stay. The independent effects of mothers education and occupation as well as fathers occupation on health outcomes were assessed by means of stepwise logistic regression analysis. Results: A total of 271 (8.0%) infants were of low birth weight, 306 (9.1%) were preterm, 410 (12.2%) had NICU admissions and 240 (7.1%) were hospitalized for more than a week. After adjusting for maternal gravidity, age, smoking during pregnancy and pregnancy-related complications, parental socioeconomic characteristics had no significant impact on low birth weight or preterm birth. NICU admission and prolonged hospitalization were significantly correlated with skilled, semi-skilled and unskilled paternal occupations. Illiterate mothers had nearly 3-5 times the risk of NICU admission and prolonged hospitalization. Conclusion: Both fathers occupation and mothers education play an important role as determinants of neonatal morbidity characteristics.