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ABSTRACT: This study was designed to test the hypothesis that 2 training programs would reduce incrementally 7-day neonatal mortality rates for low-risk institutional deliveries.
Using a train-the-trainer model, certified research midwives sequentially trained the midwives who performed deliveries in low-risk, first-level, urban, community health clinics in 2 cities in Zambia in the protocol and data collection, in the World Health Organization Essential Newborn Care (ENC) course (universal precautions and cleanliness, routine neonatal care, resuscitation, thermoregulation, breastfeeding, kangaroo care, care of small infants, and common illnesses), and in the American Academy of Pediatrics Neonatal Resuscitation Program (in-depth basic resuscitation). Data were collected during 3 periods, after implementation of each training course.
A total of 71 689 neonates were enrolled in the 3 study periods. All-cause, 7-day neonatal mortality rates decreased from 11.5 deaths per 1000 live births to 6.8 deaths per 1000 live births after ENC training (relative risk: 0.59 [95% confidence interval: 0.48-0.77]; P < .001), because of decreases in rates of deaths attributable to birth asphyxia and infection. Perinatal mortality rates but not stillbirth rates decreased. The 7-day neonatal mortality rate was decreased further after Neonatal Resuscitation Program training, after correction for loss to follow-up monitoring.
ENC training for midwives reduced 7-day neonatal mortality rates in low-risk clinics. Additional in-depth basic training in neonatal resuscitation may reduce mortality rates further.
PEDIATRICS 10/2010; 126(5):e1064-71. · 4.47 Impact Factor
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Anne Marie C Plass,
Marieke J H Baars,
Martina C Cornel,
Claire Julian-Reynier,
Irmgard Nippert, Hillary Harris,
Ulf Kristoffersson,
Jörg Schmidtke,
Elizabeth N Anionwu,
Caroline Benjamin,
Kirsty Challen,
Rodney Harris,
Leo P ten Kate
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ABSTRACT: Within Europe many guidelines exist regarding the genetic testing of minors. Predictive and presymptomatic genetic testing of minors is recommended for disorders for which medical intervention/preventive measures exist, and for which early detection improves future medical health.
This study, which is part of the larger 5th EU-framework "genetic education" (GenEd) study, aimed to evaluate the self-reported responses of nongenetic health-care providers in five different EU countries (Germany, France, Sweden, the United Kingdom, and the Netherlands) when confronted with a parent requesting presymptomatic testing on a minor child for a treatable disease.
A cross-sectional study design using postal, structured scenario-based questionnaires that were sent to 8129 general practitioners (GPs) and pediatricians, between July 2004 and October 2004, addressing self-reported management of a genetic case for which early medical intervention during childhood is beneficial, involving a minor.
Most practitioners agreed on testing the oldest child, aged 12 years (81.5% for GPs and 87.2% for pediatricians), and not testing the youngest child, aged 6 months (72.6% for GPs and 61.3% for pediatricians). After multivariate adjustment there were statistical differences between countries in recommending a genetic test for the child at the age of 8 years. Pediatricians in France (50%) and Germany (58%) would recommend a test, whereas in the United Kingdom (22%), Sweden (30%), and the Netherlands (32%) they would not.
Even though presymptomatic genetic testing in minors is recommended for disorders for which medical intervention exists, EU physicians are uncertain at what age starting to do so in young children.
Genetic Testing and Molecular Biomarkers 07/2009; 13(3):367-76. · 1.11 Impact Factor
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ABSTRACT: To evaluate the prevalence, sex distribution and causes of neonatal mortality, as well as its risk factors, in an urban Pakistani population with access to obstetric and neonatal care.
Study area women were enrolled at 20-26 weeks' gestation in a prospective population-based cohort study that was conducted from 2003 to 2005. Physical examinations, antenatal laboratory tests and anthropometric measures were performed, and gestational age was determined by ultrasound to confirm eligibility. Demographic and health data were also collected on pretested study forms by trained female research staff. The women and neonates were seen again within 48 hours postpartum and at day 28 after the birth. All neonatal deaths were reviewed using the Pattinson et al. system to assign obstetric and final causes of death; the circumstances of the death were determined by asking the mother or family and by reviewing hospital records. Frequencies and rates were calculated, and 95% confidence intervals were determined for mortality rates. Relative risks were calculated to evaluate the associations between potential risk factors and neonatal death. Logistic regression models were used to compute adjusted odds ratios.
Birth outcomes were ascertained for 1280 (94%) of the 1369 women enrolled. The 28-day neonatal mortality rate was 47.3 per 1000 live births. Preterm birth, Caesarean section and intrapartum complications were associated with neonatal death. Some 45% of the deaths occurred within 48 hours and 73% within the first week. The primary obstetric causes of death were preterm labour (34%) and intrapartum asphyxia (21%). Final causes were classified as immaturity-related (26%), birth asphyxia or hypoxia (26%) and infection (23%). Neither delivery in a health facility nor by health professionals was associated with fewer neonatal deaths. The Caesarean section rate was 19%. Almost all (88%) neonates who died received treatment and 75% died in the hospital.
In an urban population with good access to professional care, we found a high neonatal mortality rate, often due to preventable conditions. These results suggest that, to decrease neonatal mortality, improved health service quality is crucial.
Bulletin of the World Health Organisation 03/2009; 87(2):130-8. · 4.64 Impact Factor
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ABSTRACT: To evaluate the effectiveness of the American Academy of Pediatrics Neonatal Resuscitation Program (NRP) in improving knowledge, skills, and self-efficacy of nurse midwives in low-risk delivery clinics in a developing country.
We used the content specifications of the NRP material applicable to college-educated nurse midwives working in low-risk clinics in Zambia to develop performance and self-efficacy evaluations focused on principles of resuscitation, initial steps, ventilation, and chest compressions. These evaluations were administered to 127 nurse midwives before and after NRP training and 6-months later.
After training, written scores (knowledge evaluation) improved from 57%+/-14% to 80%+/-12% (mean+/-SD; P< .0001); performance scores (skills evaluation) improved the most from 43%+/-21% to 88%+/-9% (P< .0001); self-efficacy scores improved from 74%+/-14% to 90%+/-10% (P< .0001). Written and performance scores decreased significantly 6 months after training, but self-efficacy scores remained high.
As conducted, the NRP training improved educational outcomes in college-educated practicing nurse midwives. Pre-training knowledge and skills scores were relatively low despite the advanced formal education and experience of the participants, whereas the self-efficacy scores were high. NRP training has the potential to substantially improve knowledge and skills of neonatal resuscitation.
The Journal of pediatrics 01/2009; 154(4):504-508.e5. · 4.02 Impact Factor
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ABSTRACT: Anemia affects almost two-thirds of pregnant women in developing countries and contributes to maternal morbidity and mortality and to low birthweight.
To determine the prevalence of anemia and the dietary and socioeconomic factors associated with anemia in pregnant women living in an urban community setting in Hyderabad, Pakistan.
This was a prospective, observational study of 1,369 pregnant women enrolled at 20 to 26 weeks of gestation and followed to 6 weeks postpartum. A blood sample was obtained at enrollment to determine hemoglobin levels. Information on nutritional knowledge, attitudes, and practice and dietary history regarding usual food intake before and during pregnancy were obtained by trained interviewers within 1 week of enrollment.
The prevalence of anemia (defined by the World Health Organization as hemoglobin < 11.0 g/dL) in these subjects was 90.5%; of these, 75.0% had mild anemia (hemoglobin from 9.0 to 10.9 g/dL) and 14.8% had moderate anemia (hemoglobin from 7.0 to 8.9 g/dL). Only 0.7% were severely anemic (hemoglobin < 7.0 g/ dL). Nonanemic women were significantly taller, weighed more, and had a higher body mass index. Multivariate analysis after adjustment for education, pregnancy history, iron supplementation, and height showed that drinking more than three cups of tea per day before pregnancy (adjusted prevalence odds ratio [aPOR], 3.2; 95% confidence interval [CI], 1.3 to 8.0), consumption of clay or dirt during pregnancy (aPOR, 3.7; 95% CI, 1.1 to 12.3), and never consuming eggs or consuming eggs less than twice a week during pregnancy (aPOR, 1.7; 95% CI, 1.1 to 2.5) were significantly associated with anemia. Consumption of red meat less than twice a week prior to pregnancy was marginally associated with anemia (aPOR, 1.2; 95% CI, 0.8 to 1.8) but was significantly associated with lower mean hemoglobin concentrations (9.9 vs. 10.0 g/dL, p = .05) during the study period. A subanalysis excluding women with mild anemia found similar associations to those of the main model, albeit even stronger.
A high percentage of women at 20 to 26 weeks of pregnancy had mild to moderate anemia. Pica, tea consumption, and low intake of eggs and red meat were associated with anemia. Women of childbearing age should be provided nutritional education regarding food sources of iron, especially prior to becoming pregnant, and taught how food choices can either enhance or interfere with iron absorption.
Food and nutrition bulletin 06/2008; 29(2):132-9. · 1.92 Impact Factor
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ABSTRACT: The purpose of this study was to determine stillbirth risk factors and gestational age at delivery in a prospective developing country birth cohort.
At 20-26 weeks of gestation, 1369 Pakistani women were prospectively enrolled in the study; the gestational age was determined by ultrasound evaluation, and risk factors and pregnancy outcomes were assessed.
The stillbirth rate was 33.6 of 1000 births, despite the fact that 96% of the women received prenatal care, 83% of the women were attended by skilled providers in the hospital, and a 20% of the women underwent cesarean delivery. Fifty-one percent of stillbirths occurred at > or = 37 weeks of gestation and 19% occurred from 34-36 weeks of gestation. Only 4% of the births had congenital anomalies. Hemoglobin of < 8 g/dL, vaginal bleeding, and preeclampsia were associated with increased stillbirth risk.
In this developing country with reasonable technical resources defined by hospital delivery and a high cesarean delivery rate, stillbirth rates were much higher than rates in the United States. That most of the stillbirths were term and did not have congenital anomalies and that the death appeared to be recent suggests that many Pakistani stillbirths may be preventable with higher quality obstetric care.
American journal of obstetrics and gynecology 09/2007; 197(3):257.e1-8. · 3.28 Impact Factor
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Elizabeth M McClure,
Linda L Wright,
Robert L Goldenberg,
Shivaprasad S Goudar,
Sailajanandan N Parida,
Imtiaz Jehan,
Antoinette Tshefu,
Elwyn Chomba,
Fernando Althabe,
Ana Garces, Hillary Harris,
Richard J Derman,
Pinaki Panigrahi,
Cyril Engmann,
Pierre Buekens,
Michael Hambidge,
Waldemar A Carlo
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ABSTRACT: Our goal was to determine stillbirth rates in a multisite population-based study in community settings in the developing world.
Outcomes of all community deliveries in 5 resource-poor countries (Democratic Republic of Congo, Guatemala, India, Zambia, and Pakistan) and in 1 mid-level country (Argentina) were evaluated prospectively over an 18-month period. Births of > 1000 g with no signs of life were defined as stillbirth.
Outcomes of 60,324 deliveries were included. Stillbirth rates ranged from 34 per 1000 in Pakistan to 9 per 1000 births in Argentina. Increased stillbirth rates were associated significantly with lower skilled providers, out-of-hospital births, and low cesarean section rates. Maceration was present in 17.2% of stillbirths.
The stillbirth rates among births of > or = 1000 g in these developing countries were substantially higher than reported stillbirth rates in developed countries (3-5/1000 births). Because most developed countries define stillbirth as > or = 20 weeks of gestation or > or = 500 g and because almost one-half of all stillbirths are < 1000 g, the developing/developed country difference is actually larger than apparent from this study. Maceration was uncommon, which indicates that most of the deaths probably occurred during labor. The low rates of physician attendance, hospital delivery, and cesarean section deliveries suggest that stillbirth rates could be reduced by access to higher quality institutional deliveries.
American journal of obstetrics and gynecology 09/2007; 197(3):247.e1-5. · 3.28 Impact Factor
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ABSTRACT: The demand for services for predicting, diagnosing, and managing genetic diseases or diseases with a genetic component is likely to increase faster than the availability of services from medical geneticists and genetic counselors. Health care systems may also impose limitations on referrals to these specialists. If genetic problems are not to be missed and excessive referrals are to be avoided, non-geneticist practitioners will have to recognize when genetic problems should be considered, and initiate diagnosis and even management. Primary-care-centred systems offer the greatest potential for maximizing overall cost-effectiveness, by reducing the demand for specialty services not essential for improving health. But primary-care-centred systems may pose a risk of underdetection and undermanagement of genetic problems if practitioners are not actively supported by information and other educational networks. Several models for dealing with these challenges are presented, including algorithms that aid in recognizing genetic problems.
The European Journal of Public Health 04/2002; 12(1):51-6. · 2.73 Impact Factor
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ABSTRACT: Ninety-nine percent of the 4 million neonatal deaths per year occur in developing countries. The World Health Organization (WHO) Essential Newborn Care (ENC) course sets the minimum accepted standard for training midwives on aspects of infant care (neonatal resuscitation, breastfeeding, kangaroo care, small baby care, and thermoregulation), many of which are provided by the mother.
The aim of this study was to determine the association of ENC with all-cause 7-day (early) neonatal mortality among infants of less educated mothers compared with those of mothers with more education.
Protocol- and ENC-certified research nurses trained all 123 college-educated midwives from 18 low-risk, first-level urban community health centers (Zambia) in data collection (1 week) and ENC (1 week) as part of a controlled study to test the clinical impact of ENC implementation. The mothers were categorized into 2 groups, those who had completed 7 years of school education (primary education) and those with 8 or more years of education.
ENC training is associated with decreases in early neonatal mortality; rates decreased from 11.2 per 1000 live births pre-ENC to 6.2 per 1000 following ENC implementation (P < .001). Prenatal care, birth weight, race, and gender did not differ between the groups. Mortality for infants of mothers with 7 years of education decreased from 12.4 to 6.0 per 1000 (P < .0001) but did not change significantly for those with 8 or more years of education (8.7 to 6.3 per 1000, P = .14).
ENC training decreases early neonatal mortality, and the impact is larger in infants of mothers without secondary education. The impact of ENC may be optimized by training health care workers who treat women with less formal education.
Ambulatory Pediatrics 8(5):300-4. · 1.60 Impact Factor
