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Ameh C.A.,Center for Maternal and Newborn Health | Van Den Broek N.,Center for Maternal and Newborn Health
Best Practice and Research: Clinical Obstetrics and Gynaecology | Year: 2015

An estimated 289,000 maternal deaths, 2.6 million stillbirths and 2.4 million newborn deaths occur globally each year, with the majority occurring around the time of childbirth. The medical and surgical interventions to prevent this loss of life are known, and most maternal and newborn deaths are in principle preventable. There is a need to build the capacity of health-care providers to recognize and manage complications during pregnancy, childbirth and the post-partum period. Skills-and-drills competency-based training in skilled birth attendance, emergency obstetric care and early newborn care (EmONC) is an approach that is successful in improving knowledge and skills. There is emerging evidence of this resulting in improved availability and quality of care. To evaluate the effectiveness of EmONC training, operational research using an adapted Kirkpatrick framework and a theory of change approach is needed. The Making It Happen programme is an example of this. © 2015 The Authors.

Gladstone M.,University of Liverpool | Oliver C.,University of Liverpool | Van Den Broek N.,Center for Maternal and Newborn Health
PLoS ONE | Year: 2015

Background: Premature birth is the leading cause of neonatal death and second leading in children under 5. Information on outcomes of preterm babies surviving the early neonatal period is sparse although it is considered a major determinant of immediate and long-term morbidity. Methods: Systematic review of studies reporting outcomes for preterm babies in low and middle income settings was conducted using electronic databases, citation tracking, expert recommendations and "grey literature". Reviewers screened titles, abstracts and articles. Data was extracted using inclusion and exclusion criteria, study site and facilities, assessment methods and outcomes of mortality, morbidity, growth and development. The Child Health Epidemiology Reference Group criteria (CHERG) were used to assess quality. Findings: Of 197 eligible publications, few (10.7%) were high quality (CHERG). The majority (83.3%) report on the outcome of a sample of preterm babies at time of birth or admission. Only 16.0% studies report population-based data using standardised mortality definitions. In 50.5% of studies, gestational age assessment method was unclear. Only 15.8% followedup infants for 2 years or more. Growth was reported using standardised definitions but recommended morbidity definitions were rarely used. The criteria for assessment of neurodevelopmental outcomes was variable with few standardised tools - Bayley II was used in approximately 33% of studies, few studies undertook sensory assessments. Conclusions: To determine the relative contribution of preterm birth to the burden of disease in children and to inform the planning of healthcare interventions to address this burden, a renewed understanding of the assessment and documentation of outcomes for babies born preterm is needed. More studies assessing outcomes for preterm babies who survive the immediate newborn period are needed. More consistent use of data is vital with clear and aligned definitions of health outcomes in newborn (preterm or term) and intervention packages aimed to save lives and improve health. © 2015 Gladstone et al.

Aminu M.,Center for Maternal and Newborn Health | Unkels R.,Center for Maternal and Newborn Health | Mdegela M.,Center for Maternal and Newborn Health | Utz B.,Center for Maternal and Newborn Health | And 2 more authors.
BJOG : an international journal of obstetrics and gynaecology | Year: 2014

BACKGROUND: Annually, 2.6 million stillbirths occur worldwide, 98% in developing countries. It is crucial that we understand causes and contributing factors.METHODS: We conducted a systematic review of studies reporting factors associated with and cause(s) of stillbirth in low- and middle-income countries (2000-13). Narrative synthesis to compare similarities and differences between studies with similar outcome categories.MAIN RESULTS: A total of 142 studies with 2.1% from low-income settings were investigated; most report on stillbirths occurring at health facility level. Definition of stillbirth varied; 10.6% of studies (mainly upper middle-income countries) used a cut-off point of ≥22 weeks of gestation and 32.4% (mainly lower income countries) used ≥28 weeks of gestation. Factors reported to be associated with stillbirth include poverty and lack of education, maternal age (>35 or <20 years), parity (1, ≥5), lack of antenatal care, prematurity, low birthweight, and previous stillbirth. The most frequently reported cause of stillbirth was maternal factors (8-50%) including syphilis, positive HIV status with low CD4 count, malaria and diabetes. Congenital anomalies are reported to account for 2.1-33.3% of stillbirths, placental causes (7.4-42%), asphyxia and birth trauma (3.1-25%), umbilical problems (2.9-33.3%), and amniotic and uterine factors (6.5-10.7%). Seven different classification systems were identified but applied in only 22% of studies that could have used a classification system. A high percentage of stillbirths remain 'unclassified' (3.8-57.4%).CONCLUSION: To build capacity for perinatal death audit, clear guidelines and a suitable classification system to assign cause of death must be developed. Existing classification systems may need to be adapted. Better data and more data are urgently needed. © 2014 Royal College of Obstetricians and Gynaecologists.

Mgawadere F.,Center for Maternal and Newborn Health | Unkels R.,Center for Maternal and Newborn Health | van den Broek N.,Center for Maternal and Newborn Health
BJOG: An International Journal of Obstetrics and Gynaecology | Year: 2016

Objective: To compare methodology used to assign cause of and factors contributing to maternal death. Design: Reproductive Age Mortality Study. Setting: Malawi. Population: Maternal deaths among women of reproductive age. Methods: We compared cause of death as assigned by a facility-based maternal death review team, an expert panel using the International Classification of Disease, 10th revision (ICD-10) cause classification for deaths during pregnancy, childbirth and the puerperium (ICD-MM) and a computer-based probabilistic program (InterVA-4). Main outcome measures: Number and cause of maternal deaths. Results: The majority of maternal deaths occurred at a health facility (94/151; 62.3%). The estimated maternal mortality ratio was 363 per 100 000 live births (95% CI 307–425). There was poor agreement between cause of death assigned by a facility-based maternal death review team and an expert panel (κ = 0.37, 86 maternal deaths). The review team considered 36% of maternal deaths to be indirect and caused by non-obstetric complications (ICD-MM Group 7) whereas the expert panel considered only 17.4% to be indirect maternal deaths with 33.7% due to obstetric haemorrhage (ICD-MM Group 3). The review team incorrectly assigned a contributing condition rather than cause of death in up to 15.1% of cases. Agreement between the expert panel and InterVA-4 regarding cause of death was good (κ = 0.66, 151 maternal deaths). However, contributing conditions are not identified by InterVA-4. Conclusions: Training in the use of ICD-MM is needed for healthcare providers conducting maternal death reviews to be able to correctly assign underlying cause of death and contributing factors. Such information can help to identify what improvements in quality of care are needed. Tweetable abstract: For maternal deaths assigning cause of death is best done by an expert panel and helps to identify where quality of care needs to be improved. © 2016 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.

Aminu M.,Center for Maternal and Newborn Health | Utz B.,Center for Maternal and Newborn Health | Halim A.,Center for Injury Prevention and Research | van den Broek N.,Center for Maternal and Newborn Health
BMC Pregnancy and Childbirth | Year: 2014

Background: It is estimated that 18.5 million Caesarean Sections (CS) are conducted annually worldwide and about one-third of them are done without medical indications and described as " unnecessary" Although developed countries account for most of the rise in the trend of unnecessary CS, more studies report a similar trend in developing countries, putting a strain on existing but limited healthcare resources, jeopardizing families' financial security and presenting a barrier to equitable universal coverage. We examined indications for CS in public hospitals of one district in Bangladesh and explored factors influencing decision to perform the procedure.Methods: Retrospective review of case notes of 530 women who had CS in 5 public hospitals in Thakurgaon District of Bangladesh. Key Informant Interviews (KII) with 18 service providers to explore factors associated with the decision to perform a CS.Results: The commonest recorded indications for CS were: previous CS (29.4%), fetal distress (15.7%), cephalo-pelvic disproportion (10.2%), prolonged obstructed labor (8.3%) and post-term dates (7.0%). The majority (68%) of CS were performed as emergency; mainly during daytime working hours. Previous CS and " post-term dates" were common indications for elective CS with " post dates" - the commonest indication for CS in primiparous women. 16.0% of all CS were conducted for cases where alternative forms of care might have been more appropriate. Providers reported not using protocols and evidence based guidelines even though these are available. Pressure from patients and relatives to deliver by CS strongly influenced decision making. External agents from private hospitals receive a financial reward for every CS performed and are present in public hospitals to " lobby" for CS.Conclusion: Factors other than evidence based practice or the presence of a clear medical indication influence providers' decision to perform both elective and emergency CS in public hospitals in Bangladesh. © 2014 Aminu et al.; licensee BioMed Central Ltd.

Ameh C.A.,Center for Maternal and Newborn Health | Adegoke A.,Center for Maternal and Newborn Health | Pattinson R.C.,Center for Maternal and Newborn Health | van den Broek N.,Center for Maternal and Newborn Health
BJOG : an international journal of obstetrics and gynaecology | Year: 2014

Understanding the causes of and factors contributing to maternal deaths is critically important for development of interventions that reduce the global burden of maternal mortality and morbidity. The International Classification of Diseases-Maternal Mortality (ICD-MM) classification of cause of death during pregnancy, childbirth and the puerperium was applied to data obtained from maternal death reviews (MDR) for 4558 maternal deaths from five countries in sub-Saharan Africa. None of the data sets identified type of maternal death. Information obtained via MDR is generally sufficient to agree on classification of cause of death to the levels of type and group. The terms 'underlying cause of death' and 'contributing conditions' were used differently in different settings and a specific underlying cause of death was frequently not recorded. Application of ICD-MM resulted in the reclassification of 3.1% (9/285) of cases to the group 'unanticipated complications of management', previously recorded as obstetric haemorrhage or unknown. An increased number of cases were assigned to the groups pregnancy-related infection (5.6-10.2%) and pregnancies with abortive outcome (3.4-4.9%) when a clear distinction was made between women who died 'with' HIV/AIDS of obstetric causes (direct maternal death) and AIDS-related indirect maternal deaths (group 'non-obstetric complications'). Similarly, anaemia and obstructed labour were more frequently identified as contributing factors than underlying cause of death. It would be helpful if MDR forms could have explicitly stated variables called: type, group and underlying cause of death as well as a dedicated section to the most frequently occurring contributing conditions recognised in that setting. © 2014 Royal College of Obstetricians and Gynaecologists.

Banke-Thomas A.O.,Center for Maternal and Newborn Health | Madaj B.,Center for Maternal and Newborn Health | Charles A.,Center for Maternal and Newborn Health | Van Den Broek N.,Center for Maternal and Newborn Health
BMC Public Health | Year: 2015

Background: Increased scarcity of public resources has led to a concomitant drive to account for value-for-money of interventions. Traditionally, cost-effectiveness, cost-utility and cost-benefit analyses have been used to assess value-for-money of public health interventions. The social return on investment (SROI) methodology has capacity to measure broader socio-economic outcomes, analysing and computing views of multiple stakeholders in a singular monetary ratio. This review provides an overview of SROI application in public health, explores lessons learnt from previous studies and makes recommendations for future SROI application in public health. Methods: A systematic review of peer-reviewed and grey literature to identify SROI studies published between January 1996 and December 2014 was conducted. All articles describing conduct of public health SROI studies and which reported a SROI ratio were included. An existing 12-point framework was used to assess study quality. Data were extracted using pre-developed codes: SROI type, type of commissioning organisation, study country, public health area in which SROI was conducted, stakeholders included in study, discount rate used, SROI ratio obtained, time horizon of analysis and reported lessons learnt. Results: 40 SROI studies, of varying quality, including 33 from high-income countries and 7 from low middle-income countries, met the inclusion criteria. SROI application increased since its first use in 2005 until 2011, declining afterwards. SROI has been applied across different public health areas including health promotion (12 studies), mental health (11), sexual and reproductive health (6), child health (4), nutrition (3), healthcare management (2), health education and environmental health (1 each). Qualitative and quantitative methods have been used to gather information for public health SROI studies. However, there remains a lack of consensus on who to include as beneficiaries, how to account for counterfactual and appropriate study-time horizon. Reported SROI ratios vary widely (1.1:1 to 65:1). Conclusions: SROI can be applied across healthcare settings. Best practices such as analysis involving only beneficiaries (not all stakeholders), providing justification for discount rates used in models, using purchasing power parity equivalents for monetary valuations and incorporating objective designs such as case-control or before-and-after designs for accounting for outcomes will improve robustness of public health SROI studies. © 2015 Banke-Thomas et al.

Pyone T.,Center for Maternal and Newborn Health | Dickinson F.,Center for Maternal and Newborn Health | Kerr R.,Center for Maternal and Newborn Health | Boschi-Pinto C.,World Health Organization | And 2 more authors.
Bulletin of the World Health Organization | Year: 2015

Objective To describe tools used for the assessment of maternal and child health issues in humanitarian emergency settings. Methods We systematically searched MEDLINE, Web of Knowledge and POPLINE databases for studies published between January 2000 and June 2014. We also searched the websites of organizations active in humanitarian emergencies. We included studies reporting the development or use of data collection tools concerning the health of women and children in humanitarian emergencies. We used narrative synthesis to summarize the studies. Findings We identified 100 studies: 80 reported on conflict situations and 20 followed natural disasters. Most studies (76/100) focused on the health status of the affected population while 24 focused on the availability and coverage of health services. Of 17 different data collection tools identified, 14 focused on sexual and reproductive health, nine concerned maternal, newborn and child health and four were used to collect information on sexual or gender-based violence. Sixty-nine studies were done for monitoring and evaluation purposes, 18 for advocacy, seven for operational research and six for needs assessment. Conclusion Practical and effective means of data collection are needed to inform life-saving actions in humanitarian emergencies. There are a wide variety of tools available, not all of which have been used in the field. A simplified, standardized tool should be developed for assessment of health issues in the early stages of humanitarian emergencies. A cluster approach is recommended, in partnership with operational researchers and humanitarian agencies, coordinated by the World Health Organization. © 2015, World Health Organization. All Rights Reserved.

Mccauley M.E.,Center for Maternal and Newborn Health | van den Broek N.,Center for Maternal and Newborn Health | Dou L.,University of Liverpool | Othman M.,Albaha University
Cochrane Database of Systematic Reviews | Year: 2015

Background: The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin A deficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection. Objectives: To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2015) and reference lists of retrieved studies. Selection criteria: All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women. Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results: We reviewed 106 reports of 35 trials, published between 1931 and 2015. We included 19 trials including over 310,000 women, excluded 15 trials and one is ongoing. Overall, seven trials were judged to be of low risk of bias, three were high risk of bias and for nine it was unclear. 1) Vitamin A alone versus placebo or no treatment Overall, when trial results are pooled, vitamin A supplementation does not affect the risk of maternal mortality (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.65 to 1.20; four trials Ghana, Nepal, Bangladesh, UK, high quality evidence), perinatal mortality (RR 1.01, 95% CI 0.95 to 1.07; one study, high quality evidence), neonatal mortality, stillbirth, neonatal anaemia, preterm birth (RR 0.98, 95% CI 0.94 to 1.01, five studies, high quality evidence), or the risk of having a low birthweight baby. Vitamin A supplementation reduces the risk of maternal night blindness (RR 0.79, 95% CI 0.64 to 0.98; two trials). There is evidence that vitamin A supplements may reduce maternal clinical infection (RR 0.45, 95% CI 0.20 to 0.99, five trials; South Africa, Nepal, Indonesia, Tanzania, UK, low quality evidence) and maternal anaemia (RR 0.64, 95% CI 0.43 to 0.94; three studies, moderate quality evidence). 2) Vitamin A alone versus micronutrient supplements without vitamin A Vitamin A alone compared to micronutrient supplements without vitamin A does not decrease maternal clinical infection (RR 0.99, 95% CI 0.83 to 1.18, two trials, 591 women). No other primary or secondary outcomes were reported 3) Vitamin A with other micronutrients versus micronutrient supplements without vitamin A Vitamin A supplementation (with other micronutrients) does not decrease perinatal mortality (RR 0.51, 95% CI 0.10 to 2.69; one study, low quality evidence), maternal anaemia (RR 0.86, 95% CI 0.68 to 1.09; three studies, low quality evidence), maternal clinical infection (RR 0.95, 95% CI 0.80 to 1.13; I2 = 45%, two studies, low quality evidence) or preterm birth (RR 0.39, 95% CI 0.08 to 1.93; one study, low quality evidence). In HIV-positive women vitamin A supplementation given with other micronutrients was associated with fewer low birthweight babies (< 2.5 kg) in the supplemented group in one study (RR 0.67, 95% CI 0.47 to 0.96; one study, 594 women). Authors' conclusions: The pooled results of three large trials in Nepal, Ghana and Bangladesh (with over 153,500 women) do not currently suggest a role for antenatal vitamin A supplementation to reduce maternal or perinatal mortality. However, the populations studied were probably different with regard to baseline vitamin A status and there were problems with follow-up of women. There is good evidence that antenatal vitamin A supplementation reduces maternal night blindness, maternal anaemia for women who live in areas where vitamin A deficiency is common or who are HIV-positive. In addition the available evidence suggests a reduction in maternal infection, but these data are not of a high quality. © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Van Den Broek N.R.,Center for Maternal and Newborn Health | Jean-Baptiste R.,Center for Maternal and Newborn Health | Neilson J.P.,University of Liverpool
PLoS ONE | Year: 2014

Background: Assessment of risk factors for preterm birth in a population with high incidence of preterm birth and HIV infection. Methods: Secondary analysis of data for 2,149 women included in a community based randomized placebo controlled trial for the prevention of preterm birth (APPLe trial (ISRCTN84023116) with gestational age at birth determined through ultrasound measurement in early pregnancy. Multivariate Logistic Regression analyses to obtain models for three outcome variables: all preterm, early preterm, and late preterm birth. Findings: No statistical differences were noted for the prevalence of HIV infection (p = 0.30) or syphilis (p = 0.12) between women who delivered preterm versus term. BMI (Adjusted OR 0.91 (0.85-0.97); p = 0.005) and weight gain (Adjusted OR 0.89 (0.82-0.97); p = 0.006) had an independent, protective effect. Previous preterm birth doubled the odds of preterm birth (Adjusted OR 2.13 (1.198-3.80); p = 0.01). Persistent malaria (despite malaria prophylaxis) increased the risk of late preterm birth (Adjusted OR 1.99 (1.05-3.79); p = 0.04). Age <20 (Adjusted OR 1.73 (1.03-2.90); p = 0.04) and anemia (Adjusted OR 1.95 (1.08-3.52); p = 0.03) were associated with early preterm birth (<34 weeks). Conclusions: Despite claims that HIV infection is an important cause of preterm birth in Africa, we found no evidence of an association in this population (unexposed to anti-retroviral treatment). Persistent malaria was associated with late preterm birth. Maternal undernourishment and anemia were independently associated with early preterm birth. The study did not assess whether the link was direct or whether a common precursor such as chronic infection was responsible for both maternal effects and early labour. © 2014 van den Broek et al.

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