Sophie Alexander

Rates and implications of caesarean sections in Latin America: ecological study

Abstract Objectives: To estimate the incidences of caesarean sections in Latin American countries and correlate these with socioeconomic, demographic, and healthcare variables. Design: Descriptive and ecological study. Setting: 19 Latin American countries. Main outcome measures: National estimates of caesarean section rates in each country. Results: Seven countries had caesarean section rates below 15%. The remaining 12 countries had rates above 15% (range 16.8% to 40.0%). These 12 countries account for 81% of the deliveries in the region. A positive and significant correlation was observed between the gross national product per capita and rate of caesarean section (rs=0.746), and higher rates were observed in private hospitals than in public ones. Taking 15% as a medically justified accepted rate, over 850 000 unnecessary caesarean sections are performed each year in the region. Conclusions: The reported figures represent an unnecessary increased risk for young women and their babies. From the economic perspective, this is a burden to health systems that work with limited budgets. Key messages 12 of the 19 Latin American countries studied had caesarean section rates above 15%, ranging from 16.8% to 40% These12 countries account for 81% of the deliveries in the region Better socioeconomic conditions were associated with higher caesarean section rates Over 850 000 unnecessary caesarean sections are performed each year in Latin America Reduction of caesarean section rates will need concerted action from public health authorities, medical associations, medical schools, health professionals, the general population, and the media

Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group

AbstractBackgroundPostpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Several recent publications have noted an increasing trend in incidence over time. The international PPH collaboration was convened to explore the observed trends and to set out actions to address the factors identified.MethodsWe reviewed available data sources on the incidence of PPH over time in Australia, Belgium, Canada, France, the United Kingdom and the USA. Where information was available, the incidence of PPH was stratified by cause.ResultsWe observed an increasing trend in PPH, using heterogeneous definitions, in Australia, Canada, the UK and the USA. The observed increase in PPH in Australia, Canada and the USA was limited solely to immediate/atonic PPH. We noted increasing rates of severe adverse outcomes due to hemorrhage in Australia, Canada, the UK and the USA.ConclusionKey Recommendations 1. Future revisions of the International Classification of Diseases should include separate codes for atonic PPH and PPH immediately following childbirth that is due to other causes. Also, additional codes are required for placenta accreta/percreta/increta.2. Definitions of PPH should be unified; further research is required to investigate how definitions are applied in practice to the coding of data.3. Additional improvement in the collection of data concerning PPH is required, specifically including a measure of severity.4. Further research is required to determine whether an increased rate of reported PPH is also observed in other countries, and to further investigate potential risk factors including increased duration of labor, obesity and changes in second and third stage management practice.5. Training should be provided to all staff involved in maternity care concerning assessment of blood loss and the monitoring of women after childbirth. This is key to reducing the severity of PPH and preventing any adverse outcomes.6. Clinicians should be more vigilant given the possibility that the frequency and severity of PPH has in fact increased. This applies particularly to small hospitals with relatively few deliveries where management protocols may not be defined adequately and drugs or equipment may not be on hand to deal with unexpected severe PPH.

ROUTINE FORMAL FETAL MOVEMENT COUNTING AND RISK OF ANTEPARTUM LATE DEATH IN NORMALLY FORMED SINGLETONS

The routine recommendation to women to count fetal movements daily during late pregnancy for the prevention of antepartum late fetal death in normally formed singletons has been evaluated. 68,000 women were randomly allocated within thirty-three pairs of clusters either to a policy of routine counting or to standard care, which might involve selective use of formal counting or informal noting of movements. Antepartum death rates for normally formed singletons were similar in the two groups, regardless of cause of prior risk status. Despite the counting policy, most of these fetuses were dead by the time the mothers received medical attention. The study does not rule out a beneficial effect, but at best, the policy would have to be used by about 1250 women to prevent 1 unexplained antepartum late fetal death, and an adverse effect is just as likely. In addition, formal routine counting would use considerable extra resources.

Maternal mortality in developed countries: Not just a concern of the past**

Objective To review the activities in selected developed countries for strategies to identify maternal deaths, the impact of these strategies on underreporting, and the information needed to understand the events leading to death. Data Sources We reviewed the literature from the United States, Europe, and Australia for publications dealing with maternal death identification and investigation from 1980 to April 1995. We also obtained information directly from researchers involved in major maternal mortality studies. Methods of Study Selection We included all 31 reports (from 14 countries) that discussed methods to improve the ascertainment of maternal deaths beyond the routine use of vital registration. Because of the nature of the subject matter, almost all reports relied on descriptive epidemiology. Data Extraction and Synthesis We found that a variety of methods can be used to improve the ascertainment of maternal deaths, including linkage of birth and fetal death certificates, check-boxes on death certificates, periodic review of deaths of reproductive-age women, and ongoing birth registries and medical audits. Information from a variety of sources is also needed to understand the events leading to death. Conclusion The numbers of deaths due to pregnancy and its complications are underestimated in most developed countries. Improved ascertainment of maternal death is needed to determine the magnitude of the problem and to assess trends and identify risk groups, allowing development of appropriate and effective strategies to prevent the morbidity and mortality associated with pregnancy.

Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population-based study: the MOMS-B survey

Objective  To describe the incidence of three conditions of acute severe maternal morbidity in selected regions in nine European countries.

Underreporting of pregnancy-related mortality in the United States and Europe.

OBJECTIVE: Available maternal mortality statistics do not allow valid international comparisons. Our objective was to uniformly measure underreporting of mortality from pregnancy in official statistics from selected regions within the U.S. and Europe, and to provide comparable revised profiles of pregnancy-related mortality. METHODS: We developed a standardized enhanced method to uniformly identify and classify pregnancy-associated deaths from 2 U.S. states, Massachusetts and North Carolina, and 2 European countries, Finland and France, for the years 1999–2000. Identification method included the use of all data available from the death certificate as well as computerized linkage of births and deaths registers. All cases were reviewed and classified by an international panel of experts. RESULTS: Four-hundred-and-four pregnancy-associated deaths were identified and reviewed. Underestimation of mortality causally related to pregnancy based on International Classification of Diseases cause-of-death codes alone varied from 22% in France to 93% in Massachusetts. Underreporting was greater in the regions with lower initial maternal mortality ratios. The distribution of causes of pregnancy-related mortality was specific to each region. The leading causes of death were cardiovascular conditions in Massachusetts; hemorrhage, pregnancy-induced hypertension, and peripartum cardiomyopathy in North Carolina; noncardiovascular medical conditions in Finland; and hemorrhage in France. CONCLUSION: This study shows the limitations of maternal mortality statistics based on International Classification of Diseases cause-of-death codes alone. Linkage of births and deaths registers should routinely be used in the ascertainment of pregnancy-related deaths. In addition, extension of the definition of a maternal death should be considered. Beyond pregnancy-related mortality ratios, considering the specific distribution of causes-of-death is important to define prevention strategies. LEVEL OF EVIDENCE: II-2

Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe

Background  The EUropean Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe.

Stillbirths and infant deaths among migrants in industrialized countries

Introduction. The relation of migration to infant outcomes is unclear. There are studies which show that some migrant groups have similar or even better outcomes than those from the receiving country. Equally, raised risk of adverse outcomes for other migrant groups has been reported. Objective. We sought to determine (1) if migrants in western industrialized countries have consistently higher risks of stillbirth, neonatal mortality, or infant mortality, (2) if there are migrant sub‐groups at potentially higher risk, and (3) what might be the explanations for any risk differences found. Design and Setting. Systematic review of the literature on perinatal health outcomes among migrants in western industrialized countries. Methods and Main outcome measures. Drawing on a larger systematic review of perinatal outcomes and migration, we reviewed studies including mortality outcomes (stillbirths and infant deaths). Results. Eligible studies gave conflicting results. Half (53%) reported worse mortality outcomes, one third (35%) reported no differences and a few (13%) reported better outcomes for births to migrants compared to the receiving country population. Refugees were the most vulnerable group. For non‐refugees, non‐European migrants in Europe and foreign‐born blacks in the United States had the highest excess mortality. In general, adjustment of background factors did not explain the increased mortality rate among migrants. Regarding causes of death, higher preterm birth rates explained the increased mortality figures among some migrant groups. The increased mortality from congenital anomalies may be related to restricted access to screening, but also to differing attitudes to screening and termination of pregnancy. Conclusions. Mortality risk among babies born to migrants is not consistently higher, but appears to be greatest among refugees, non‐European migrants to Europe, and foreign‐born blacks in the US. To understand this variation better, more information is needed about migrant background, such as length of time in receiving country and receiving country language fluency. Additional data on demographic, health care, biological, medical, and socioeconomic risk factors should be gathered and analyzed in greater detail.

Effect of a collector bag for measurement of postpartum blood loss after vaginal delivery: cluster randomised trial in 13 European countries.

Objective To evaluate the effectiveness of the systematic use of a transparent plastic collector bag to measure postpartum blood loss after vaginal delivery in reducing the incidence of severe postpartum haemorrhage. Design Cluster randomised trial. Setting 13 European countries. Participants 78 maternity units and 25 381 women who had a vaginal delivery. Interventions Maternity units were randomly assigned to systematic use of a collector bag (intervention group) or to continue to visually assess postpartum blood loss after vaginal delivery (control group). Main outcome measures The primary outcome was the incidence of severe postpartum haemorrhage in vaginal deliveries, defined as a composite of one or more of blood transfusion, intravenous plasma expansion, arterial embolisation, surgical procedure, admission to an intensive care unit, treatment with recombinant factor VII, and death. Results Severe postpartum haemorrhage occurred in 189 of 11 037 of vaginal deliveries (1.71%) in the intervention group compared with 295 of 14 344 in the control group (2.06%). The difference was not statistically significant either in individual level analysis (adjusted odds ratio 0.82, 95% confidence interval 0.26 to 2.53) or in cluster level analysis (difference in weighted mean rate adjusted for baseline rate 0.16%, 95% confidence interval −0.69% to 1.02%). Conclusion Compared with visual estimation of postpartum blood loss the use of a collector bag after vaginal delivery did not reduce the rate of severe postpartum haemorrhage. Trial registration Current Controlled Trials ISRCTN66197422.

Randomised controlled trial of routine cervical examinations in pregnancy

Abstract Summary Preterm delivery is strongly associated with neonatal mortality and morbidity. In some European countries, cervical examinations are used routinely during pregnancy to identify women at risk of preterm delivery. We sought to evaluate the efficacy and secondary effects of these routine cervical examinations. We did a randomised controlled trial in seven European countries, comparing two policies—namely, an attempt to do a cervical examination at every prenatal visit (2803 women) and avoidance of cervical examination if possible (2799). The median number of cervical examinations was 6 in the experimental group and 1 in the controls. There were 6·7% preterm ( Our findings do not support the routine use of cervical examinations during pregnancy.