Nelly Zavaleta

Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America

BACKGROUND Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics. METHODS For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions. We also obtained institutional-level data. FINDINGS We obtained data for 97,095 of 106,546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24-43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43-57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity. Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%. INTERPRETATION High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in six developing countries

OBJECTIVE To report stillbirth and early neonatal mortality and to quantify the relative importance of different primary obstetric causes of perinatal mortality in 171 perinatal deaths from 7993 pregnancies that ended after 28 weeks in nulliparous women. METHODS A review of all stillbirths and early newborn deaths reported in the WHO calcium supplementation trial for the prevention of pre-eclampsia conducted at seven WHO collaborating centres in Argentina, Egypt, India, Peru, South Africa and Viet Nam. We used the Baird-Pattinson system to assign primary obstetric causes of death and classified causes of early neonatal death using the International classification of diseases and related health problems, Tenth revision (ICD-10). FINDINGS Stillbirth rate was 12.5 per 1000 births and early neonatal mortality rate was 9.0 per 1000 live births. Spontaneous preterm delivery and hypertensive disorders were the most common obstetric events leading to perinatal deaths (28.7% and 23.6%, respectively). Prematurity was the main cause of early neonatal deaths (62%). CONCLUSIONS Advancements in the care of premature infants and prevention of spontaneous preterm labour and hypertensive disorders of pregnancy could lead to a substantial decrease in perinatal mortality in hospital settings in developing countries.

Potential contribution of maternal zinc supplementation during pregnancy to maternal and child survival.

Mild-to-moderate zinc deficiency may be relatively common worldwide, but the public health importance of this degree of zinc deficiency is not well defined. The purpose of this review was to provide a conceptual framework for evaluating the public health importance of maternal zinc deficiency as it relates to fetal growth and development, complications of pregnancy, labor and delivery, and maternal and infant health. The mechanisms through which zinc deficiency could influence health outcomes are well described. The results of experimental studies conducted in animal models have motivated concern about the potential health effects of mild-to-moderate maternal zinc deficiency. Observational studies in human populations have produced strong associations between poor maternal zinc status and various indicators of poor pregnancy outcome, but supplementation trials have not produced strong, or even consistent results. Supplementation trials are needed to define the public health importance of maternal zinc deficiency worldwide.

World Health Organisation multicentre randomised trial of supplementation with vitamins C and E among pregnant women at high risk for pre‐eclampsia in populations of low nutritional status from developing countries

Objective  To determine if vitamin C and E supplementation in high‐risk pregnant women with low nutritional status reduces pre‐eclampsia.

Maternal near miss and maternal death in the World Health Organization's 2005 global survey on maternal and perinatal health

OBJECTIVE To develop an indicator of maternal near miss as a proxy for maternal death and to study its association with maternal factors and perinatal outcomes. METHODS In a multicenter cross-sectional study, we collected maternal and perinatal data from the hospital records of a sample of women admitted for delivery over a period of two to three months in 120 hospitals located in eight Latin American countries. We followed a stratified multistage cluster random design. We assessed the intra-hospital occurrence of severe maternal morbidity and the latters association with maternal characteristics and perinatal outcomes. FINDINGS Of the 97,095 women studied, 2964 (34 per 1000) were at higher risk of dying in association with one or more of the following: being admitted to the intensive care unit (ICU), undergoing a hysterectomy, receiving a blood transfusion, suffering a cardiac or renal complication, or having eclampsia. Being older than 35 years, not having a partner, being a primipara or para > 3, and having had a Caesarean section in the previous pregnancy were factors independently associated with the occurrence of severe maternal morbidity. They were also positively associated with an increased occurrence of low and very low birth weight, stillbirth, early neonatal death, admission to the neonatal ICU, a prolonged maternal postpartum hospital stay and Caesarean section. CONCLUSION Women who survive the serious conditions described could be pragmatically considered cases of maternal near miss. Interventions to reduce maternal and perinatal mortality should target women in these high-risk categories.

Efficacy of rice-based oral rehydration solution containing recombinant human lactoferrin and lysozyme in Peruvian children with acute diarrhea.

Objective:To compare glucose and rice-based oral rehydration solution with rice-based oral rehydration solution containing recombinant human lactoferrin and recombinant human lysozyme in diarrhea outcomes. Patients and Methods:We conducted a randomized, double-blind controlled trial in children with acute diarrhea and dehydration. One hundred and forty children 5 to 33 months old were block randomized to receive low osmolarity WHO-ORS (G-ORS), rice-based ORS (R-ORS), or rice-based ORS plus lactoferrin and lysozyme (Lf/Lz-R-ORS). Intake and output were monitored for 48 h in the ORU, with continued monitoring through home and clinic follow-up for 14 d. Results:The G-ORS and R-ORS groups did not show any differences in diarrhea outcomes and were therefore combined as the control group. Intent-to-treat analysis showed a significant decrease in duration of diarrhea (3.67 d vs 5.21 d, P = 0.05) in the Lf/Lz-R-ORS group as compared with the control group and a significant increase in the number of children who achieved 48 h with solid stool, 85% vs 69% (P < 0.05). There were also decreases in volume of diarrhea and the percentage of children who had a new diarrhea episode after achieving the endpoint. Conclusions:Addition of recombinant human lactoferrin and lysozyme to a rice-based oral rehydration solution had beneficial effects on children with acute diarrhea.

Methodological considerations in implementing the WHO Global Survey for Monitoring Maternal and Perinatal Health.

OBJECTIVE To set up a global system for monitoring maternal and perinatal health in 54 countries worldwide. METHODS The WHO Global Survey for Monitoring Maternal and Perinatal Health was implemented through a network of health institutions, selected using a stratified multistage cluster sampling design. Focused information on maternal and perinatal health was abstracted from hospital records and entered in a specially developed online data management system. Data were collected over a two- to three-month period in each institution. The project was coordinated by WHO and supported by WHO regional offices and country coordinators in Africa and the Americas. FINDINGS The initial survey was implemented between September 2004 and March 2005 in the African and American regions. A total of 125 institutions in seven African countries and 119 institutions in eight Latin American countries participated. CONCLUSION This project has created a technologically simple and scientifically sound system for large-scale data management, which can facilitate programme monitoring in countries.

Fetal Neurobehavioral Development: A Tale of Two Cities

Longitudinal neurobehavioral development was examined in 237 fetuses of low-risk pregnancies from 2 distinct populations--Baltimore, Maryland, and Lima. Peru--at 20, 24, 28, 32, 36, and 38 weeks gestation. Data were based on digitized Doppler-based fetal heart rate (FHR) and fetal movement (FM). In both groups. FHR declined while variability, episodic accelerations, and FM-FHR coupling increased, with discontinuities evident between 28 and 32 weeks gestation. Fetuses in Lima had higher FHR and lower variability, accelerations, and FM-FHR coupling. Declines in trajectories were typically observed 1 month sooner in Lima, which magnified these disparities. Motor activity differences were less consistent. No sex differences in fetal neurobehaviors were detected. It is concluded that population factors can influence the developmental niche of the fetus.

Maternal gestational zinc supplementation does not influence multiple aspects of child development at 54 mo of age in Peru

BACKGROUND Zinc is necessary for central nervous system development, and maternal zinc status has been associated with developmental differences in offspring. OBJECTIVE The objective was to evaluate differences in cognitive, social, and behavioral function in Peruvian children at 54 mo of age whose mothers participated during pregnancy in a zinc supplementation trial. DESIGN We attempted to follow up 205 children from a prenatal zinc supplementation trial and present data on 184 (90%) children-86 whose mothers took 25 mg zinc/d in addition to 60 mg iron and 250 microg folic acid and 98 whose mothers took iron and folic acid only. Following a standardized protocol, we assessed childrens intelligence, language and number skills, representational ability, interpersonal understanding, and adaptive behavior and behavioral adjustment. We also assessed aspects of the mother (eg, age, education, verbal intelligence, stresses, and social support in parenting) and the home environment [HOME (Home Observation for the Measurement of the Environment) inventory]. RESULTS No differences were observed between any of the tests used to characterize cognitive, social, or behavioral development (P > 0.05). Child sex, parity, or treatment compliance did not modify the effects of supplementation on any outcomes. CONCLUSION The addition of zinc to prenatal supplements did not influence developmental outcomes in Peruvian children when assessed at 4.5 y of age.

Efficacy and Acceptability of Two Iron Supplementation Schedules in Adolescent School Girls in Lima, Peru

To assess the efficacy and acceptability of a daily and intermittent iron supplementation, a double-blind, placebo-controlled trial was conducted in a public school located in periurban Lima, Peru. Adolescent girls (n = 312), 12-18 y old, were randomly assigned to one of the following three groups: 1) 60 mg iron as ferrous sulfate daily from Monday to Friday; 2) 60 mg iron as ferrous sulfate 2 d/wk and 3 d placebo (intermittent); 3) placebo, from Monday to Friday. Field workers gave the girls supplements during school hours for 17 wk; 296 girls completed the trial. Girls took 94% of the expected dose of 85 pills. Few side effects were reported. Postintervention, hemoglobin (Hb), serum ferritin (SF) and free erythrocyte protoporphyrin (FEP) were improved significantly in the iron-supplemented groups compared with placebo (P<0.05). Daily supplements led to higher Hb increases than intermittent supplements (P<0.05), but SF and FEP were similar between the two groups. Thus, both iron supplementation schedules were efficacious in preventing iron deficiency in adolescent girls through the school system, and the daily schedule was better than the intermittent schedule at increasing Hb values and reducing anemia.