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Author(s): Torvid Kiserud, Gilda Piaggio, Guillermo Carroli, Mariana Widmer, José Carvalho, Lisa Neerup Jensen, Daniel Giordano, José Guilherme Cecatti, Hany Abdel Aleem, Sameera A. Talegawkar, Alexandra Benachi, Anke Diemert, Antoinette [...]

Objective To assess the frequency of elective induction of labour and its determinants in selected Latin America countries; quantify success in attaining vaginal delivery, and compare rates of caesarean and adverse maternal and perinatal outcomes after elective induction versus spontaneous labour in low-risk pregnancies. Methods Of 37 444 deliveries in women with low-risk pregnancies, 1847 (4.9%) were electively induced. The factors associated with adverse maternal and perinatal outcomes among cases of spontaneous and induced onset of labour were compared. Odds ratios for factors potentially associated with adverse outcomes were calculated, as were the relative risks of having an adverse maternal or perinatal outcome (both with their 95% confidence intervals). Adjustment using multiple logistic regression models followed these analyses. Findings Of 11 077 cases of induced labour, 1847 (16.7%) were elective. Elective inductions occurred in 4.9% of women with low-risk pregnancies (37 444). Oxytocin was the most common method used (83% of cases), either alone or combined with another. Of induced deliveries, 88.2% were vaginal. The most common maternal adverse events were: (i) a higher postpartum need for uterotonic drugs, (ii) a nearly threefold risk of admission to the intensive care unit; (iii) a fivefold risk of postpartum hysterectomy, and (iv) an increased need for anaesthesia/analgesia. Perinatal outcomes were satisfactory except for a 22% higher risk of delayed breastfeeding (i.e. initiation between 1 hour and 7 days postpartum). Conclusion Caution is mandatory when indicating elective labour induction because the increased risk of maternal and perinatal adverse outcomes is not outweighed by clear benefits. Objectif Evaluer la frequence du declenchement du travail sans indication medicale et ses determinants dans une selection de pays d'Amerique latine, quantifier la reussite d'un accouchement par voie vaginale et comparer les taux de cesariennes et d'issues perinatales et maternelles negatives apres le declenchement du travail sans indication medicale par rapport au travail spontane, dans des grossesses a faible risque. Methodes Sur 37 444 accouchements de femmes presentant des grossesses a faible risque, 1 847 (4,9%) ont ete declenches sans indication medicale. On a compare les facteurs associes aux issues perinatales et maternelles negatives dans des cas de debut de travail spontane et declenche. On a calcule les rapports des cotes des facteurs potentiellement associes aux issues negatives, ainsi que les risques relatifs d'issue perinatale ou maternelle negative (tous deux avec un intervalle de confiance de 95%). Suite a ces analyses, un ajustement a ete effectue a l'aide de plusieurs modeles de regression logistique. Resultats Sur 11 077 cas de travail declenche, 1 847 (16,7%) l'ont ete sans indication medicale. Un declenchement du travail sans indication medicale a ete effectue chez 4,9% des femmes des grossesses a faible risque (37 444). L'ocytocine etait la methode la plus communement utilisee (83% des cas), soit administree seule, soit combinee avec une autre methode. Pour les accouchements sans indication medicale, 88,2% ont eu lieu par voie vaginale. Les evenements maternels negatifs les plus communs etaient: (i) un besoin superieur de medicaments uterotoniques postpartum, (il) un risque presque multiplie par 3 d'admission en unite de soins intensifs; (iii) un risque multiplie par 5 d'hysterectomie postpartum et (iv) une augmentation du besoin d'anesthesie/analgesie. Les issues perinatales etaient satisfaisantes, a l'exception d'une augmentation de 22% du risque d'allaitement retarde (c'est-a-dire une initiation entre 1 heure et 7 jours apres l'accouchement). Conclusion II est indispensable de faire preuve de prudence lors de la preconisation d'un accouchement sans indication medicale, car l'augmentation du risque d'issues perinatales et maternelles negatives n'est pas compensee par des avantages clairs. Objetivo Evaluar la frecuencia de los partos inducidos electivos y sus factores determinantes en determinados paises de Latinoamerica; cuantificar el exito en la consecucion de partos vaginales y comparar los porcentajes de cesareas y de resultados maternos y perinatales adversos tras un parto inducido electivo con respecto a un parto espontaneo en embarazos de bajo riesgo. Metodos De 37 444 partos de mujeres con embarazos de bajo riesgo, 1847 (4,9%) fueron partos inducidos etectivos. Se compararon los factores asociados a resultados matemos y perinatales adversos en los casos de inicio del parto espontaneo e inducido. Se calcularon los cocientes de posibilidades para los factores posiblemente asociados a resultados adversos, asi como los riesgos relacionados con un resultado materno o perinatal adverso (ambos con un intervalo de confianza del 95%). Despues de llevar a cabo estos analisis, se realizo un ajuste empleando modelos de regresion logistica multiple. Resultados De los 11 077 casos de parto inducido, 1847 (16,7%) fueron electivos. Las inducciones electivas se produjeron en un 4,9% de mujeres con embarazos de bajo riesgo (37 444). El metodo mas utilizado fue la oxitocina (83% de los casos), como farmaco unico o en combinacion con otros medicamentos. Un 88,2% de los partos inducidos fueron vaginales. Los acontecimientos matemos adversos mas comunes fueron: (i) una mayor necesidad de medicamentos uterotonicos tras el parto, (ii) un riesgo casi tres veces mayor de ingreso en la unidad de cuidados intensivos; (iii) un riesgo cinco veces mayor de histerectomia posparto y (iv) una mayor necesidad de anestesicos/analgesicos. Los resultados perinataies fueron satisfactorios excepto por un riesgo un 22% mayor de lactancia materna retardada (es decir, el inicio de la misma entre 1 hora y 7 dias despues del parto). Conclusion La precaucion es obligatoria a la hora de recomendar una induccion electiva del parto, ya que el aumento del riesgo de resultados adversos matemos y perinatales no se ve compensado por unos beneficios claros., Introduction Elective labour induction without any medical or obstetric indication has been increasing in recent years. In some countries, 10% of all deliveries are electively induced. (1-4) This increase has [...]

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. Objectif Mettre en place dans 54 pays repartis dans l'ensemble du monde un systeme mondial de surveillance de la sante maternelle et perinatale. Methodes L'Enquete mondiale sur la surveillance de la sante maternelle et perinatale de I'OMS s'est operee par le biais d'un reseau d'etablissements de soins, selectionnes par echantillonnage en grappe stratifie a plusieurs niveaux. Une information ciblee sur la sante maternelle et perinatale a ete extraite des registres hospitaliers et entree dans un systeme de gestion des donnees en ligne, specialement developpe. Les donnees ont ete recueillies sur une periode de deux a trois mois dans chaque etablissement. Le projet a ete coordonne par I'OMS et appuye par les bureaux regionaux de I'OMS et par ses coordinateurs nationaux en Afrique et dans les Ameriques. Resultats L'enquete initiale a ete realisee entre septembre 2004 et mars 2005 en Afrique et dans les Ameriques. Ont participe au total a l'enquete 125 etablissements de sept pays africains et 119 etablissements de huit pays d'Amerique latine. Conclusion Ce projet a cree un systeme technologiquement simple et scientifiquement rigoureux pour la gestion grande echelle des donnees, pouvant faciliter la surveillance programmatique dans les pays. Objetivo Establecer un sistema mundial de vigilancia de la salud materna y perinatal en 54 paises de todo el mundo. Metodos La Encuesta mundial OMS de vigilancia de la salud materna y perinatal se llevo a cabo a traves de una red de instituciones sanitarias seleccionadas mediante muestreo polietapico estratificado por conglomerados. La informacion focalizada y resumida sobre la salud materna y perinatal extraida a partir de las historias clinicas se introdujo en un sistema de gestion de datos en linea especialmente desarrollado. A lo largo de un periodo de dos a tres meses se reunieron datos en cada institucion. El proyecto fue coordinado por la OMS y respaldado por las oficinas regionales de la OMS y los coordinadores en los paises en Africa y las Americas. Resultados La encuesta inicial se llevo a cabo entre septiembre de 2004 y marzo de 2005 en las regiones de Africa y de las Americas. Participaron en total 125 instituciones de siete paises africanos y 119 instituciones de ocho paises latinoamericanos. Conclusion Este proyecto ha generado un sistema tecnologicamente sencillo y cientificamente solido para gestionar datos a gran escala, lo cual puede facilitar la vigilancia de los programas en los paises. [TEXT NOT REPRODUCIBLE IN ASCII], Introduction The WHO Global Survey on Maternal and Perinatal Health aims to develop a network of health institutions worldwide that collects up-to-date information on services provided and on how evidence-based [...]

Background Perinatal mortality and morbidity continue to be major global health challenges strongly associated with prematurity and reduced fetal growth, an issue of further interest given the mounting evidence that fetal growth in general is linked to degrees of risk of common noncommunicable diseases in adulthood. Against this background, WHO made it a high priority to provide the present fetal growth charts for estimated fetal weight (EFW) and common ultrasound biometric measurements intended for worldwide use. Methods and Findings We conducted a multinational prospective observational longitudinal study of fetal growth in low-risk singleton pregnancies of women of high or middle socioeconomic status and without known environmental constraints on fetal growth. Centers in ten countries (Argentina, Brazil, Democratic Republic of the Congo, Denmark, Egypt, France, Germany, India, Norway, and Thailand) recruited participants who had reliable information on last menstrual period and gestational age confirmed by crown-rump length measured at 8-13 wk of gestation. Participants had anthropometric and nutritional assessments and seven scheduled ultrasound examinations during pregnancy. Fifty-two participants withdrew consent, and 1,387 participated in the study. At study entry, median maternal age was 28 y (interquartile range [IQR] 25-31), median height was 162 cm (IQR 157-168), median weight was 61 kg (IQR 55-68), 58% of the women were nulliparous, and median daily caloric intake was 1,840 cal (IQR 1,487-2,222). The median pregnancy duration was 39 wk (IQR 38-40) although there were significant differences between countries, the largest difference being 12 d (95% CI 8-16). The median birthweight was 3,300 g (IQR 2,980-3,615). There were differences in birthweight between countries, e.g., India had significantly smaller neonates than the other countries, even after adjusting for gestational age. Thirty-one women had a miscarriage, and three fetuses had intrauterine death. The 8,203 sets of ultrasound measurements were scrutinized for outliers and leverage points, and those measurements taken at 14 to 40 wk were selected for analysis. A total of 7,924 sets of ultrasound measurements were analyzed by quantile regression to establish longitudinal reference intervals for fetal head circumference, biparietal diameter, humerus length, abdominal circumference, femur length and its ratio with head circumference and with biparietal diameter, and EFW. There was asymmetric distribution of growth of EFW: a slightly wider distribution among the lower percentiles during early weeks shifted to a notably expanded distribution of the higher percentiles in late pregnancy. Male fetuses were larger than female fetuses as measured by EFW, but the disparity was smaller in the lower quantiles of the distribution (3.5%) and larger in the upper quantiles (4.5%). Maternal age and maternal height were associated with a positive effect on EFW, particularly in the lower tail of the distribution, of the order of 2% to 3% for each additional 10 y of age of the mother and 1% to 2% for each additional 10 cm of height. Maternal weight was associated with a small positive effect on EFW, especially in the higher tail of the distribution, of the order of 1.0% to 1.5% for each additional 10 kg of bodyweight of the mother. Parous women had heavier fetuses than nulliparous women, with the disparity being greater in the lower quantiles of the distribution, of the order of 1% to 1.5%, and diminishing in the upper quantiles. There were also significant differences in growth of EFW between countries. In spite of the multinational nature of the study, sample size is a limiting factor for generalization of the charts. Conclusions This study provides WHO fetal growth charts for EFW and common ultrasound biometric measurements, and shows variation between different parts of the world., Author(s): Torvid Kiserud 1,2,*, Gilda Piaggio 3,4,*, Guillermo Carroli 5, Mariana Widmer 6,*, José Carvalho 4, Lisa Neerup Jensen 7, Daniel Giordano 5, José Guilherme Cecatti 8, Hany Abdel Aleem [...]

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. Objectif Faire etat de la mortinatalite et de la mortalite neonatale precoce et quantifier l'importance relative des principales causes obstetricales de mortalite perinatale observees pour 171 deces perinatals lies a 7993 grossesses interrompues apres la 28eme semaine chez des femmes nullipares. Methodes L'examen a porte sur tous les cas de mortinatalite et deces neonatals precoces signales dans l'essai OMS de supplementation calcique pour la prevention de la preeclampsie mene dans sept centres collaborateurs situes en Afrique du Sud, en Argentine, en Egypte, en Inde, au Perou et au Vietnam. On a utilise le systeme de Baird-Pattinson pour attribuer les principales causes obstetricales de deces et classe les causes des deces neonatals precoces sur la base de la Classification internationale des maladies et des problemes de sante connexes, dixieme revision (CIM 10). Resultats Le taux de mortinatalite est de 12,5 pour 1000 naissances et le taux de mortalite neonatale precoce de 9,0 pour 1000 naissances vivantes. L'accouchement premature spontane et l'hypertension gravidique sont les problemes obstetricaux les plus frequemment a l'origine d'un deces perinatal (respectivement 28,7% et 23,6 %). La prematurite est la principale cause de deces neonatal precoce (62 %). Conclusion Des progres dans les soins aux prematures et la prevention du travail premature spontane et de l'hypertension gravidique permettraient d'obtenir une diminution sensible de la mortalite perinatale en milieu hospitalier dans les pays en developpement. Objetivo Informar sobre la mortinatalidad y la mortalidad neonatal precoz y cuantificar la importancia relativa de diferentes causas obstetricas primarias de mortalidad perinatal en 171 defunciones perinatales correspondientes a 7993 embarazos de mas de 28 semanas en mujeres nuliparas. Metodos Se examinaron todos los casos de mortinatalidad y defuncion precoz de recien nacidos notificados en un ensayo OMS de administracion de suplementos de calcio para la prevencion de la preeclampsia, llevado a cabo en siete centros colaboradores de la OMS en la Argentina, Egipto, la India, el Peru, Sudafrica y Viet Nam. Usamos el sistema de Baird-Pattinson para asignar causas obstetricas primarias de muerte y causas clasificadas de mortalidad neonatal precoz mediante la Clasificacion Estadistica Internacional de Enfermedades y Problemas de Salud Conexos, decima revision (CIE-10). Resultados La tasa de mortinatalidad fue del 12,5 por 1000 nacimientos, y la tasa de mortalidad neonatal precoz, de 9,0 por 1000 nacidos vivos. EI parto pretermino espontaneo y los trastornos hipertensivos fueron los casos obstetricos mas comunes asociados a las defunciones perinatales (28,7% y 23,6%, respectivamente). La prematuridad fue la causa principal de las defunciones neonatales precoces (62%). Conclusiones Los progresos de la atencion a los lactantes prematuros y la prevencion del parto pretermino espontaneo y de los trastornos hipertensivos del embarazo podrian propiciar una disminucion sustancial de la mortalidad perinatal en los entornos hospitalarios en los paises en desarrollo., Introduction A two-thirds reduction of mortality in children less than 5 years old by 2015 is one of the UN Millennium Development Goals. (1) Despite a decline in mortality in [...]

This paper reviews the efficacy of nutrition interventions to prevent or treat impaired fetal growth. Searches were made for Cochrane systematic reviews and randomized controlled trials published before October 2002. Balanced protein energy supplementation reduced the risk of small for gestational age (SGA) by 30% (95%Cl: 20% to 43%) while one trial conducted in New York, U.S., reported a negative effect of high protein supplementation on SGA (RR 1.58; 95%Cl: 1.03-2.41). Calcium supplementation protected against low birth weight (RR 0.83; 95%Cl: 0.71-0.98). Micronutrient supplements did not affect birth weight, except for magnesium supplementation, which reduced the risk of SGA by 30%. This finding, however, needs or be interpreted with caution because of methodological issues in the data analysis. Programmatic recommendations can be made only for intervening with balanced protein energy supplements, especially in population with a high prevalence of undernutrition. Research is needed to determine the efficacy of multiple micronutrient supplementation and the effect of single micronutrients supplementation on specific growth outcomes such as fetal organ and bone growth. In addition, the public health relevance of these outcomes and their relation to morbidity need to be evaluated. KEY WORDS: * nutritional interventions * fetal growth * birth weight * small for gestational age * randomized controlled trials

This overview assesses the effectiveness of nutritional interventions to prevent or treat maternal morbidity, mortality and preterm delivery. Cochrane systematic reviews and other up-to-date systematic reviews and individual randomized controlled trials were sought. Searches were carried out up to July 2002. Iron and folate supplements reduce anemia and should be included in antenatal care programs. Calcium supplementation to women at high risk of hypertension during pregnancy or low calcium intake reduced the incidence of both preeclampsia and hypertension. Fish oil and vitamins E and C are promising for preventing preeclampsia and preterm delivery and need further testing. Vitamin A and [beta]-carotene reduced maternal mortality in a large trial; ongoing trials should provide further evaluation. No specific nutrient supplementation was identified for reducing preterm delivery. Nutritional advice, magnesium, fish oil and zinc supplementation appear promising and should be tested alone or together in methodologically sound randomized controlled trials. Anema in pregnancy can be prevented and treated effectively. Considering the multifactorial etiology of the other conditions evaluated, it is unlikely that any specific nutrient on its own, blanket interventions or magic bullets will prevent or treat preeclampsia, hemorrhage, obstructed labor, infections, preterm delivery or death during pregnancy. The few promising interventions for specific outcomes should be tested or reconsidered when results of ongoing trials become available. Until then, women and their families should receive support to improve their diets as a general health rule, which is a basic human right. KEY WORDS: * nutritional interventions * maternal morbidity * preterm delivery * randomized controlled trials

To the Editor.-- We read the article by Ceriani Cemadas et al (1) with great interest. The authors studied the effects of delayed cord clamping (DCC) on neonatal hematocrit values [...]

BACKGROUND. The umbilical cord is usually clamped immediately after birth. There is no sound evidence to support this approach, which might deprive the newborn of some benefits such as an increase in iron storage. OBJECTIVES. We sought to determine the effect of timing of cord clamping on neonatal venous hematocrit and clinical outcome in term newborns and maternal postpartum hemorrhage. METHODS. This was a randomized, controlled trial performed in 2 obstetrical units in Argentina on neonates born at term without complications to mothers with uneventful pregnancies. After written parental consents were obtained, newborns were randomly assigned to cord clamping within the first 15 seconds (group 1), at 1 minute (group 2), or at 3 minutes (group 3) after birth. The infants' venous hematocrit value was measured 6 hours after birth. RESULTS. Two hundred seventy-six newborns were recruited. Mean venous hematocrit values at 6 hours of life were 53.5% (group 1), 57.0% (group 2), and 59.4% (group 3). Statistical analyses were performed, and results were equivalent among groups because the hematocrit increase in neonates with late clamping was within the prespecified physiologic range. The prevalence of hematocrit at <45% (anemia) was significantly lower in groups 2 and 3 than in group 1. The prevalence of hematocrit at >65% was similar in groups 1 and 2 (4.4% and 5.9%, respectively) but significantly higher in group 3 (14.1%) versus group 1 (4.4%). There were no significant differences in other neonatal outcomes and in maternal postpartum hemorrhage. CONCLUSIONS. Delayed cord clamping at birth increases neonatal mean venous hematocrit within a physiologic range. Neither significant differences nor harmful effects were observed among groups. Furthermore, this intervention seems to reduce the rate of neonatal anemia. This practice has been shown to be safe and should be implemented to increase neonatal iron storage at birth. KEY WORDS. anemia, cord blood, delivery of care, newborn, full term, perinatal medicine.