William Stones

Examining the “Urban Advantage” in Maternal Health Care in Developing Countries

Andrew Channon and colleagues outline the complexities of urban advantage in maternal health where the urban poor often have worse access to health care than women in rural areas.

Stillbirths: ending preventable deaths by 2030

Efforts to achieve the new worldwide goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, the number of annual stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2.6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda. This Series paper summarises findings from previous papers in this Series, presents new analyses, and proposes specific criteria for successful integration of stillbirths into post-2015 initiatives for womens and childrens health. Five priority areas to change the stillbirth trend include intentional leadership; increased voice, especially of women; implementation of integrated interventions with commensurate investment; indicators to measure effect of interventions and especially to monitor progress; and investigation into crucial knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths, including stillbirths.

Gestational weight gain standards based on women enrolled in the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project: a prospective longitudinal cohort study.

Objective To describe patterns in maternal gestational weight gain (GWG) in healthy pregnancies with good maternal and perinatal outcomes. Design Prospective longitudinal observational study. Setting Eight geographically diverse urban regions in Brazil, China, India, Italy, Kenya, Oman, United Kingdom, and United States, April 2009 to March 2014. Participants Healthy, well nourished, and educated women enrolled in the Fetal Growth Longitudinal Study component of the INTERGROWTH-21st Project, who had a body mass index (BMI) of 18.50-24.99 in the first trimester of pregnancy. Main outcome measures Maternal weight measured with standardised methods and identical equipment every five weeks (plus/minus one week) from the first antenatal visit (<14 weeks’ gestation) to delivery. After confirmation that data from the study sites could be pooled, a multilevel, linear regression analysis accounting for repeated measures, adjusted for gestational age, was applied to produce the GWG values. Results 13 108 pregnant women at <14 weeks’ gestation were screened, and 4607 met the eligibility criteria, provided consent, and were enrolled. The variance within sites (59.6%) was six times higher than the variance between sites (9.6%). The mean GWGs were 1.64 kg, 2.86 kg, 2.86 kg, 2.59 kg, and 2.56 kg for the gestational age windows 14-18+6 weeks, 19-23+6 weeks, 24-28+6 weeks, 29-33+6 weeks, and 34-40+0 weeks, respectively. Total mean weight gain at 40 weeks’ gestation was 13.7 (SD 4.5) kg for 3097 eligible women with a normal BMI in the first trimester. Of all the weight measurements, 71.7% (10 639/14 846) and 94.9% (14 085/14 846) fell within the expected 1 SD and 2 SD thresholds, respectively. Data were used to determine fitted 3rd, 10th, 25th, 50th, 75th, 90th, and 97th smoothed GWG centiles by exact week of gestation, with equations for the mean and standard deviation to calculate any desired centiles according to gestational age in exact weeks. Conclusions Weight gain in pregnancy is similar across the eight populations studied. Therefore, the standards generated in this study of healthy, well nourished women may be used to guide recommendations on optimal gestational weight gain worldwide.

Maternal Tetanus Toxoid Vaccination and Neonatal Mortality in Rural North India

Objectives Preventable neonatal mortality due to tetanus infection remains common. We aimed to examine antenatal vaccination impact in a context of continuing high neonatal mortality in rural northern India. Methods and Findings Using the third round of the Indian National Family Health Survey (NFHS) 2005–06, mortality of most recent singleton births was analysed in discrete-time logistic model with maternal tetanus vaccination, together with antenatal care utilisation and supplementation with iron and folic acid. 59% of mothers reported receiving antenatal care, 48% reported receiving iron and folic acid supplementation and 68% reported receiving two or more doses of tetanus toxoid (TT) vaccination. The odds of all-cause neonatal death were reduced following one or more antenatal dose of TT with odds ratios (OR) of 0.46 (95% CI 0.26 to 0.78) after one dose and 0.45 (95% CI 0.31 to 0.66) after two or more doses. Reported utilisation of antenatal care and iron-folic acid supplementation did not influence neonatal mortality. In the statistical model, 16% (95% CI 5% to 27%) of neonatal deaths could be attributed to a lack of at least two doses of TT vaccination during pregnancy, representing an estimated 78,632 neonatal deaths in absolute terms. Conclusions Substantial gains in newborn survival could be achieved in rural North India through increased coverage of antenatal TT vaccination. The apparent substantial protective effect of a single antenatal dose of TT requires further study. It may reflect greater population vaccination coverage and indicates that health programming should prioritise universal antenatal coverage with at least one dose.

A cognitive behavioural based assessment of women with chronic pelvic pain.

From population-based surveys, chronic pelvic pain (CPP) in women is a common condition with a spectrum of associated disability and distress. Those seen by gynaecologists in a referral setting often have substantial impairment of function and mood disturbance. Because in most cases, the aetiology of CPP cannot be explained and the range of effective interventions remains limited, treatment of CPP might easily result in a sense of frustration not only for the patient but also for the gynaecologist. To avoid this situation in clinical practice, a structured assessment of women suffering from CPP using a cognitive behavioural model, is suggested. This type of assessment provides information about the impact of CPP on a particular patients daily life. It also facilitates referral for pain management. Future studies are needed to show further evidence of benefit of this approach for women with CPP.

The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH-21st Project

To identify risk factors for antepartum stillbirth, including fetal growth restriction, among women with well‐dated pregnancies and access to antenatal care.

Health-care professionals in midwifery care

www.thelancet.com Vol 384 September 27, 2014 1169 How many clinicians will claim that their daily practice is evidence based? Although systematic reviews are used where available, clinical tradition still dominates. It is therefore reassuring to fi nd that for midwifery practices, as many as 56 outcomes have been shown to be improved by their application, although nine others have been identifi ed as “ineff ective”. As a caution, intrapartum stillbirth is now recognised as a high priority not just for high income settings, and midwives need the instruments and skills to identify and respond to fetal compromise more eff ectively. Standards from the International Federation of Gynecology and Obstetrics (FIGO) on fetal monitoring are currently under development, but meanwhile let us not confuse “no evidence for benefi t” with “evidence of no benefi t”. The Series authors challenge examination of technical elements of care delivered in isolation and highlight the lack of evidence from high-burden countries. Mary Renfrew and colleagues conclude that “Studies of care by midwives in low-income and middleincome settings, integrated into the health system and working in teams with medical staff and with properly trained support staff , are an urgent priority” while the modelling work of Caroline Homer’s group shows the huge potential impact of midwifery when provided within a functional health system with referral and transfer. These insights should prompt a rapid response from both implementation researchers and donors for realisation at scale, with investment suffi cient to gather robust supporting evidence. Where does attention need to be focused to strengthen eff ective team working so as to fully actualise the gains from investments in midwifery? In reality, it is not just obstetricians and midwives who need to work eff ectively together, but many other cadres including obstetric nurses, doctors in training, paediatric staff , and anaesthetists. In some low-income and middle-income countries, clinical offi cers or surgical technicians are the main providers of caesarean delivery, with generally good outcomes compared with delivery by medical staff . FIGO has endorsed this “task shifting” approach, helping to overcome perceptions of professional resistance and refl ecting willingness to go beyond traditional professional boundaries. Clinical offi cers are usually not involved in intrapartum care and so their working relationships with midwives, who are the decision makers regarding operative delivery in these settings, are crucial to good outcomes and may overcome some reported problems with newborn care. Often it is not so much the intervention itself that is challenging but rather the decision. In well resourced settings, delivery decisions are sometimes driven by newborn health rather than maternal safety—for example, when a fetal anomaly is identifi ed and these decisions must include the paediatricians. Similarly, anaesthetists now play an integral part in delivery planning. In line with this increasing complexity and diversity of care needs, obstetric nursing and midwifery roles and relationships have evolved. However, it should not be forgotten that those with complex care needs still require humanistic supportive care refl ected in the core competencies of the midwife. Two “blind-spots” were identifi ed in the Lancet Midwifery Series: respectful care and overmedicalisation. The fi rst of these is very much a preoccupation of the associations of health-care professionals, and let us hope that, as related standards and guidelines are developed and disseminated, they are taken seriously by those designing and commissioning services so that they are not seen as an optional extra. With regard to overmedicalisation, it is unfortunate that the evidence base is so scarce: to blame obstetricians Health-care professionals in midwifery care

Prevalence of genital chlamydia infection in urban women of reproductive age, Nairobi, Kenya

BackgroundChlamydia trachomatis is one of the major causes of sexually transmitted infections throughout the world. Most infections are asymptomatic and remain undetected. Burden of disease in the Kenyan population is not well characterised. This study was done to define the prevalence of genital Chlamydia infection in a representative female population.FindingsA cross-sectional study design was employed. All women attending out-patient clinics (antenatal, gynaecology, family planning) and accident and emergency departments at two study sites over a five month period were invited to consent to completion of a questionnaire and vaginal swab collection. A rapid point-of-care immunoassay based test was performed on the swabs. Women who tested positive for Chlamydia were offered treatment, together with their partner(s), and advised to come for a follow-up test.A total of 300 women were tested. The prevalence of genital Chlamydia trachomatis was found to be 6% (95% CI 3.31% – 8.69%). The prevalence was higher in women who represented a higher socioeconomic level, but this difference was not significant (p=0.061). Use of vaginal swabs was observed to be a more acceptable form of sample collection.ConclusionThe prevalence of genital Chlamydia is significant in our female population. There is a justifiable need to institute opportunistic screening programs to reduce the burden of this disease. Rapid and low cost point-of-care testing as a potential component of sexually transmitted infection (STI) screening can be utilised.

Health-related quality of life changes among users of depot medroxyprogesterone acetate for contraception

BACKGROUND Depot medroxyprogesterone acetate (DMPA) may have other noncontraceptive effects that could impact on the quality of life. The objective of this study was to assess the health-related quality of life changes associated with the use of DMPA for contraception. STUDY DESIGN A prospective, observational study using the Short Form-36 quality of life questionnaire. RESULTS After 6 months of use, the participants had an improved physical summary score, mean change [5.64 (95% confidence interval [CI], 1.87-9.4), p=.054]. There was no significant change in sexual function [5.33 (95% CI, -2.15 to 12.81), p=.0858] and mental summary score [-0.51 (95% CI, -1.90 to 2.92), p=.432]. The main side effect of DMPA was menstrual irregularity (32.5%); 17.2% of the participants found amenorrhea desirable. CONCLUSION Besides its contraceptive efficacy, DMPA is associated with an improvement in perceived physical health with no apparent adverse effect on mental health and sexual function.

External cephalic version in East, Central, and Southern Africa

To evaluate the views of maternity care providers in East, Central, and Southern Africa on external cephalic version (ECV), and its determinants, with the aim of drawing lessons for practice.