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Blood pressure measurement is a marker of antenatal care quality. In well resourced settings, lower blood pressure cutoffs for hypertension are associated with adverse pregnancy outcomes. We aimed to study the associations between blood pressure thresholds and adverse outcomes and the diagnostic test properties of these blood pressure cutoffs in low-resource settings.We did a secondary analysis of data from 22 intervention clusters in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials (NCT01911494) in India (n=6), Mozambique (n=6), and Pakistan (n=10). We included pregnant women aged 15-49 years (12-49 years in Mozambique), identified in their community by trained community health workers, who had data on blood pressure measurements and outcomes. The trial was unmasked. Maximum blood pressure was categorised as: normal blood pressure (systolic blood pressure [sBP]120 mm Hg and diastolic blood pressure [dBP]80 mm Hg), elevated blood pressure (sBP 120-129 mm Hg and dBP80 mm Hg), stage 1 hypertension (sBP 130-139 mm Hg or dBP 80-89 mm Hg, or both), non-severe stage 2 hypertension (sBP 140-159 mm Hg or dBP 90-109 mm Hg, or both), or severe stage 2 hypertension (sBP ≥160 mm Hg or dBP ≥110 mm Hg, or both). We classified women according to the maximum blood pressure category reached across all visits for the primary analyses. The primary outcome was a maternal, fetal, or neonatal mortality or morbidity composite. We estimated dose-response relationships between blood pressure category and adverse outcomes, as well as diagnostic test properties.Between Nov 1, 2014, and Feb 28, 2017, 21 069 women (6067 in India, 4163 in Mozambique, and 10 839 in Pakistan) contributed 103 679 blood pressure measurements across the three CLIP trials. Only women with non-severe or severe stage 2 hypertension, as discrete diagnostic categories, experienced more adverse outcomes than women with normal blood pressure (risk ratios 1·29-5·88). Using blood pressure categories as diagnostic thresholds (women with blood pressure within the category or any higher category vs those with blood pressure in any lower category), dose-response relationships were observed between increasing thresholds and adverse outcomes, but likelihood ratios were informative only for severe stage 2 hypertension and maternal CNS events (likelihood ratio 6·36 [95% CI 3·65-11·07]) and perinatal death (5·07 [3·64-7·07]), particularly stillbirth (8·53 [5·63-12·92]).In low-resource settings, neither elevated blood pressure nor stage 1 hypertension were associated with maternal, fetal, or neonatal mortality or morbidity adverse composite outcomes. Only the threshold for severe stage 2 hypertension met diagnostic test performance standards. Current diagnostic thresholds for hypertension in pregnancy should be retained.University of British Columbia, the BillMelinda Gates Foundation.

OBJECTIVE AND METHODS: We conducted a prospective observational cohort study in 458 pregnant and puerperal women, with confirmed COVID-19 at Hospital San Jose, Santiago, Chile, to determine the impact of COVID-19 on pregnancy and confirm safety and feasibility of a management protocol based on clinical presentation of the disease. RESULTS: 25.5% (117/458) of women were severe and 74.4% (341/458) mild presentation. Three percent (9/341) of mild presentations required a subsequent hospitalization. Overall, 26/458 women (5.6%) were admitted to ICU, and 13/458 (2.8%) required mechanical ventilation. One maternal death occurred at 49-days postpartum. Severe presentation, infection above 24 weeks, and comorbidities were associated with an adverse maternal outcome. Of total deliveries, 16.5% (36/217) were

Supplemental Digital Content is available in the text., In pregnancy in well-resourced settings, limited data suggest that higher blood pressure (BP) visit-to-visit variability may be associated with adverse pregnancy outcomes. Included were pregnant women in 22 intervention clusters of the CLIP (Community-Level Interventions for Preeclampsia) cluster randomized trials, who had received at least 2 prenatal contacts from a community health worker, including standardized BP measurement. Mixed-effects adjusted logistic regression assessed relationships between pregnancy outcomes and both BP level (median [interquartile range]) and visit-to-visit variability (SD and average real variability [ARV], adjusted for BP level), among all women and those who became hypertensive. The primary outcome was the CLIP composite of maternal and perinatal mortality and morbidity. Among 17 770 pregnancies, higher systolic and diastolic BP levels were associated with increased odds of the composite outcome per 5 mm Hg increase in BP (odds ratio [OR], 1.05 [95% CI, 1.03–1.07] and OR, 1.08 [1.06–1.11], respectively). Higher BP visit-to-visit variability was associated with increased odds, per a SD increase in BP variability measure, of (1) hypertension (systolic: OR, 2.09 [1.98–2.21] for SD and 1.52 [1.45–1.60] for ARV; diastolic: OR, 2.70 [2.54–2.87] for SD and 1.86 [1.76–1.96] for ARV); and (2) the composite outcome (systolic: OR, 1.10 [1.06–1.14] for SD and 1.06 [1.02–1.10] for ARV; diastolic: OR, 1.07 [1.03–1.11] for SD and 1.06 [1.02–1.09] for ARV). In 3 less-developed countries, higher BP level and visit-to-visit variability predicted adverse pregnancy outcomes, providing an opportunity for high-definition medicine.

Improving maternal and perinatal care is a global priority. Simulation training and novel applications of simulation for intrapartum care may help to reduce preventable deaths worldwide. Evaluation studies have published details of the effectiveness of simulation training for obstetric emergencies, exploring clinical and non-clinical factors as well as the impact on patient outcomes (both maternal and neonatal). This review summarized the many uses of simulation in obstetric emergencies from training to assessment. It also described the adaption of training in low-resource settings and the evidence behind the equipment recommended to support simulation training. The review also discussed novel applications for simulation such as its use in the development of a new device for assisted vaginal birth and its potential role in Cesarean section training. This study analyzed the financial implications of simulation training and how this may impact the delivery of such training packages, considering that simulation should be developed and utilized as a key tool in the development of safe intrapartum care in both emergency and non-emergency settings, in innovation and product development.

Human leishmaniasis is an emerging problem in Italy and is on the increase in the Emilia-Romagna region, northeastern part of the country. Nevertheless, studies dealing with the molecular characterization of Leishmania spp. circulating in these areas are limited. In the present work, we explored the genetic polymorphism of Leishmania isolates from 28 cases of canine leishmaniasis and three cases of human visceral leishmaniasis (VL), which occurred in 2013-2014 in the Emilia-Romagna region. The characterization was carried out in comparison with nine human isolates of Leishmania from other VL endemic Italian regions and two reference strains. Nucleic acid from 31 Leishmania-positive phlebotomine sandfly pools, sampled in 2012-2013 in the Emilia-Romagna region, were also evaluated. DNA amplification and sequencing of the ribosomal internal transcribed spacer-1 and of a repetitive nuclear region on chromosome 31 were carried out for genotyping. Two size polymorphic targets were also analyzed by PCR, the cpb E/F-gene and the k26-gene. Altogether, the analysis showed the circulation of different Leishmania infantum genotypes in the Emilia-Romagna region: two genotypes found in dogs from public kennels were similar to VL isolates from other Italian regions, whereas a third genotype was detected in VL cases of the Emilia-Romagna region and in all but one of the sandfly pools. The combined molecular tools applied in this study can constitute a helpful support for parasite tracking (e.g., in outbreak investigations) and for a better understanding of the epidemiological evolution of leishmaniasis in northeastern Italy.

Background Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. Methods The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12-49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193-268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0·56 [95% CI 0·43-0·66]) or InterVA-5 (κ=0·44 [0·30-0·57]), and InterVA-4 and InterVA-5 (κ=0·72 [0·60-0·84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0·48 [0·38-0·58]), poor for physician review versus InterVA-5 (κ=0·36 [0·27-0·46]), and good for InterVA-4 versus InterVA-5 (κ=0·69 [0·59-0·79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0·04 [0·00-0·15]). Interpretation Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. Funding University of British Columbia (grantee of the Bill & Melinda Gates Foundation).

Background Domesticated and wild swine play an important role as reservoir hosts of Trichinella spp. and a source of infection for humans. Little is known about the survival of Trichinella larvae in muscles and the duration of anti-Trichinella antibodies in pigs with long-lasting infections. Methods Sixty pigs were divided into three groups of 20 animals and infected with 10,000 larvae of Trichinella spiralis, Trichinella britovi or Trichinella pseudospiralis. Four pigs from each group were sacrificed at 2, 6, 12, 18 and 24 months post-infection (p.i.) and the number of larvae per gram (LPG) of muscles was calculated. Serum samples were tested by ELISA and western blot using excretory/secretory (ES) and crude antigens. Results Trichinella spiralis showed the highest infectivity and immunogenicity in pigs and larvae survived in pig muscles for up to 2 years p.i. In these pigs, the IgG level significantly increased at 30 days p.i. and reached a peak at about 60 days p.i., remaining stable until the end of the experiment. In T. britovi-infected pigs, LPG was about 70 times lower than for T. spiralis at 2 months p.i. and only very few infecting larvae were detected at 6 months p.i., whereas no larvae were detected at 12, 18 and 24 months p.i. At 6 months p.i., degenerated/calcified larvae and cysts were detected in the muscles by trichinoscopy and histology. The IgG pattern showed by T. britovi-infected pigs was similar to that of T. spiralis-infected pigs, although seroconversion occurred some days later. The larval burden of T. pseudospiralis was slightly greater than for T. britovi at 2 months p.i., but no larvae were detected at 6 and 12 months p.i. In T. pseudospiralis-infected pigs, seroconversion occurred slowly, as in T. britovi-infected pigs. The IgG level showed a significant drop at 6 months p.i. and declining to the cut-off value at 12 months p.i. Conclusions The longer survival of T. spiralis in pigs in comparison with the other two species highlights its exceptional dissemination potential. These results provide an explanation of the controversial data collected by parasitological and serological tools in the course of epidemiological investigations.

Background High levels of maternal and newborn mortality and morbidity remain a daunting reality in many low-income countries. Several interventions delivered during antenatal care have been shown to improve maternal and newborn outcomes, but stockouts of medical supplies at point of care can prevent implementation of these services. We aimed to evaluate whether a supply chain strategy based on the provision of kits could improve quality of care. Methods We did a pragmatic, stepped-wedge, cluster-randomised controlled trial at ten antenatal care clinics in Mozambique. Clinics were eligible if they were not already implementing the proposed antenatal care package; they served at least 200 new pregnant women per year; they had Maternal and Child Health (MCH) nurses; and they were willing to participate. All women attending antenatal care visits at the participating clinics were included in the trial. Participating clinics were randomly assigned to shift from control to intervention on prespecified start dates. The intervention involved four components (kits with medical supplies, a cupboard to store these supplies, a tracking sheet to monitor stocks, and a one-day training session). The primary outcomes were the proportion of women screened for anaemia and proteinuria, and the proportion of women who received mebendazole in the first antenatal care visit. The intervention was delivered under routine care conditions, and analyses were done according to the intention-to-treat principle. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201306000550192. Findings Between March, 2014, and January, 2016, 218 277 antenatal care visits were registered, with 68 598 first and 149 679 follow-up visits. We found significant improvements in all three primary outcomes. In first visits, 5519 (14·6%) of 37 826 women were screened for anaemia in the control period, compared with 30 057 (97·7%) of 30 772 in the intervention period (adjusted odds ratio 832·40; 99% CI 666·81–1039·11; p

Even though dairy cows are known carriers of Arcobacter species and raw or minimally processed foods are recognized as the main sources of human Arcobacter infections in industrialized countries, data on Arcobacter excretion patterns in cows and in milk are scant. This study aimed to identify potentially pathogenic Arcobacter species in a dairy herd and to investigate the routes of Arcobacter transmission among animals and the potential sources of cattle infection and milk contamination. A strategy of sampling the same 50 dairy animals, feed, water, and milk every month for a 10-month period, as well as the sampling of quarter milk, animal teats, the milking environment, and animals living on the farm (pigeons and cats), was used to evaluate, by pulsed-field gel electrophoresis (PFGE), the characteristic patterns in animals, their living environment, and the raw milk they produced. Of the 463 samples collected, 105 (22.6%) were positive for Arcobacter spp. by culture examination. All the matrices except quarter milk and pigeon gut samples were positive, with prevalences ranging from 15 to 83% depending on the sample. Only three Arcobacter species, Arcobacter cryaerophilus (54.2%), A. butzleri (34.2%), and A. skirrowii (32.3%), were detected. PFGE analysis of 370 isolates from positive samples provided strong evidence of Arcobacter circulation in the herd: cattle likely acquire the microorganisms by orofecal transmission, either by direct contact or from the environment, or both. Water appears to be a major source of animal infection. Raw milk produced by the farm and collected from a bulk tank was frequently contaminated (80%) by A. butzleri ; our PFGE findings excluded primary contamination of milk, whereas teats and milking machine surfaces could be sources of Arcobacter milk contamination.

Background Visceral leishmaniasis (VL) caused by Leishmania infantum is an ongoing health problem in southern Europe, where dogs are considered the main reservoirs of the disease. Current data point to a northward spread of VL and canine leishmaniasis (CanL) in Italy, with new foci in northern regions previously regarded as non-endemic. Methodology/Principal findings Multilocus microsatellite typing (MLMT) was performed to investigate genetic diversity and population structure of L. infantum on 55 samples from infected humans, dogs and sand flies of the E-R region between 2013 and 2017. E-R samples were compared with 10 L. infantum samples from VL cases in other Italian regions (extra E-R) and with 52 strains within the L. donovani complex. Data displayed significant microsatellite polymorphisms with low allelic heterozygosity. Forty-one unique and eight repeated MLMT profiles were recognized among the L. infantum samples from E-R, and ten unique MLMT profiles were assigned to the extra E-R samples. Bayesian analysis assigned E-R samples to two distinct populations, with further sub-structuring within each of them; all CanL samples belonged to one population, genetically related to Mediterranean MON-1 strains, while all but one VL cases as well as the isolate from the sand fly Phlebotomus perfiliewi fell under the second population. Conversely, VL samples from other Italian regions proved to be genetically similar to strains circulating in dogs. Conclusions/Significance A peculiar epidemiological situation was observed in northeastern Italy, with the co-circulation of two distinct populations of L. infantum; one population mainly detected in dogs and the other population detected in humans and in a sand fly. While the classical cycle of CanL in Italy fits well into the data obtained for the first population, the population found in infected humans exhibits a different cycle, probably not involving a canine reservoir. This study can contribute to a better understanding of the population structure of L. infantum circulating in northeastern Italy, thus providing useful epidemiologic information for public health authorities., Author summary Visceral leishmaniasis is a sand fly-borne disease caused by protozoan parasites of the genus Leishmania. Leishmania infantum is the only parasitic species circulating in Italy and dogs are considered the main reservoirs of the disease. In this study, 55 L. infantum strains obtained from humans, dogs and sand flies from the Emiliana-Romagna (E-R) region, northeastern Italy, were assessed using multilocus microsatellite typing, a tool applied for population genetic studies. Results were compared with those obtained from 10 samples of visceral leishmaniasis cases occurring in other Italian regions and with 52 strains of the L. donovani complex from other foci of leishmaniasis. Our genetic analysis revealed that canine and human L. infantum strains from the E-R region were separated in two distinct populations; all samples obtained from dogs belonged to one population, while all but one human samples as well as a sand fly sample fell under another population. Samples from patients with visceral leishmaniasis from other Italian regions proved to be genetically similar to strains circulating in dogs. Our findings raise questions on the role of dogs as main reservoirs for human visceral leishmaniasis in the investigated area of northeastern Italy.

Background A prolonged and complicated second stage of labour is associated with serious perinatal complications. The Odon device is an innovation intended to perform instrumental vaginal delivery presently under development. We present an evaluation of the feasibility and safety of delivery with early prototypes of this device from an early terminated clinical study. Methods Hospital-based, multi-phased, open-label, pilot clinical study with no control group in tertiary hospitals in Argentina and South Africa. Multiparous and nulliparous women, with uncomplicated singleton pregnancies, were enrolled during the third trimester of pregnancy. Delivery with Odon device was attempted under non-emergency conditions during the second stage of labour. The feasibility outcome was delivery with the Odon device defined as successful expulsion of the fetal head after one-time application of the device. Results Of the 49 women enrolled, the Odon device was inserted successfully in 46 (93%), and successful Odon device delivery as defined above was achieved in 35 (71%) women. Vaginal, first and second degree perineal tears occurred in 29 (59%) women. Four women had cervical tears. No third or fourth degree perineal tears were observed. All neonates were born alive and vigorous. No adverse maternal or infant outcomes were observed at 6-weeks follow-up for all dyads, and at 1 year for the first 30 dyads. Conclusions Delivery using the Odon device is feasible. Observed genital tears could be due to the device or the process of delivery and assessment bias. Evaluating the effectiveness and safety of the further developed prototype of the BD Odon Device™ will require a randomized-controlled trial., Reproductive Health, 15

A quantitative risk assessment (RA) was developed to estimate haemolytic-uremic syndrome (HUS) cases in paediatric population associated with the consumption of raw milk sold in vending machines in Italy. The historical national evolution of raw milk consumption phenomenon since 2008, when consumer interest started to grow, and after 7Âyears of marketing adjustment, is outlined. Exposure assessment was based on the official Shiga toxin-producing Escherichia coli O157:H7 (STEC) microbiological records of raw milk samples from vending machines monitored by the regional Veterinary Authorities from 2008 to 2014, microbial growth during storage, consumption frequency of raw milk, serving size, consumption preference and age of consumers. The differential risk considered milk handled under regulation conditions (4°C throughout all phases) and the worst time–temperature field handling conditions detected. In case of boiling milk before consumption, we assumed that the risk of HUS is fixed at zero. The model estimates clearly show that the public health significance of HUS cases due to raw milk STEC contamination depends on the current variability surrounding the risk profile of the food and the consumer behaviour has more impact than milk storage scenario. The estimated HUS cases predicted by our model are roughly in line with the effective STEC O157-associated HUS cases notified in Italy only when the proportion of consumers not boiling milk before consumption is assumed to be 1%. Raw milk consumption remains a source of E.Âcoli O157:H7 for humans, but its overall relevance is likely to have subsided and significant caution should be exerted for temporal, geographical and consumers behaviour analysis. Health education programmes and regulatory actions are required to educate people, primarily children, on other STEC sources.

Transition from design to adoption of innovations must be evidence-based and inform product development, regulatory approval and adoption.

To (1) determine how intended users interact with and use the BD Odon Device in simulation, (2) use these findings to alter progressively the design of the BD Odon Device and (3) validate that these changes have improved the ability of practitioners to use the BD Odon Device.Human factors evaluation study.Simulation suite designed to mimic delivery room.Three hundred and ninety simulated operative births, performed by 100 practising clinicians.Simulated operative vaginal births performed using the BD Odon Device and the device Instructions for use were subjected to three formative human factors evaluations and one human factors validation test. Following each evaluation, findings were reviewed and the design of the BD Odon Device and Instructions for use were modified.Successful performance of an operative vaginal birth using the BD Odon Device in accordance with provided training and Instructions for use.Using version two of the BD Odon Device, and following exposure to face-to-face training and written instructions, 25% of accouchers were able successfully to perform a simulated operative vaginal birth. In the final evaluation, following device design and training material alterations, all accouchers were able successfully to perform a simulated operative vaginal birth using version four of the BD Odon Device.Human factors evaluations have enabled a multi-professional device and training materials design team to alter the design of the BD Odon Device and the Instructions for use in an evidence-based fashion. This process has resulted in a device which has a predictable and likely safe pattern of use.Human Factors evaluations help make the BD Odon Device safe and usable for clinical practice.

Objectives Caesarean section (CS) rates are increasing worldwide and maternal request is cited as one of the main reasons for this trend. Women's preferences for route of delivery are influenced by popular media, including magazines. We assessed the information on CS presented in Spanish women's magazines. Design Systematic review. Setting Women's magazines printed from 1989 to 2009 with the largest national distribution. Sample Articles with any information on CS. Methods Articles were selected, read and abstracted in duplicate. Sources of information, scientific accuracy, comprehensiveness and women's testimonials were objectively extracted using a content analysis form designed for this study. Main outcome measures Accuracy, comprehensiveness and sources of information. Results Most (67%) of the 1223 selected articles presented exclusively personal opinion/birth stories, 12% reported the potential benefits of CS, 26% mentioned the short-term and 10% mentioned the long-term maternal risks, and 6% highlighted the perinatal risks of CS. The most frequent short-term risks were the increased time for maternal recovery (n = 86), frustration/feelings of failure (n = 83) and increased post-surgical pain (n = 71). The most frequently cited long-term risks were uterine rupture (n = 57) and the need for another CS in any subsequent pregnancy (n = 42). Less than 5% of the selected articles reported that CS could increase the risks of infection (n = 53), haemorrhage (n = 31) or placenta praevia/accreta in future pregnancies (n = 6). The sources of information were not reported by 68% of the articles. Conclusions The portrayal of CS in Spanish women's magazines is not sufficiently comprehensive and does not provide adequate important information to help the readership to understand the real benefits and risks of this route of delivery.

Background Poor-quality care during institutional births in low- and middle-income countries is a major contributing factor to preventable maternal and newborn harm, but progress has been slow in identifying effective methods to address these deficiencies at scale. Based on the success of checklist programs in other disciplines, WHO led the design and field testing of the WHO Safe Childbirth Checklist—a 29-item tool that targets the major causes of maternal and newborn mortality globally. Methods The development process consisted of comprehensive evidence and guideline review, in-person consultation with content experts and other key stakeholders, iterative refinement through ongoing discussions with a wide collaborator network, and field evaluation for usability in 9 countries, primarily in Africa and Asia. Pilot testing in South India demonstrated major improvement in health workers’ delivery of essential safety practices after introduction of the program. Results WHO has launched a global effort to support further evaluation of the program in a range of contexts, and a randomized trial is underway in North India to measure the effectiveness of the program in reducing severe maternal, fetal, and newborn harm. Conclusion A novel checklist program has been developed to support health workers in low-resource settings to prevent avoidable childbirth-related deaths.

To evaluate the risk of recurrence of adverse perinatal outcomes in second pregnancies in developing countries.Data from the 2004-2008 Global Survey on Maternal and Perinatal Health were used to determine the outcomes of singleton second pregnancies for 61 780 women in 23 developing countries. The mother-infant pairs had been followed up until discharge or for 7 days postpartum.At the end of their second pregnancies, women whose first pregnancy had ended in stillbirth (n = 1261) or been followed by neonatal death (n = 1052) were more likely than women who had not experienced either outcome to have given birth to a child with a birth weight of 1500 g (odds ratio, OR: 2.52 and 2.78, respectively) or 1500-2499 g (OR: 1.22 and 1.60, respectively), or to an infant requiring admission to an intensive care unit (OR: 1.64 and 1.68, respectively). At the end of their second pregnancies, those whose first pregnancy had ended in a stillbirth were at increased risk of another stillbirth (OR: 2.35) and those whose first infant had died as a neonate were at increased risk of having the second infant die within the first 7 days of life (OR: 2.82). These trends were found to be largely unaffected by the continent in which the women lived.In the developing world, a woman whose first pregnancy ends in stillbirth or is followed by the death of the neonate is at increased risk of experiencing the same outcomes in her second pregnancy.Évaluer le risque de récidive des issues périnatales indésirables lors des deuxièmes grossesses dans les pays en développement.Les données de l'Enquête mondiale sur la santé maternelle et périnatale menée sur la période 2004-2008 ont été utilisées pour déterminer les résultats des deuxièmes grossesses uniques auprès de 61 780 femmes dans 23 pays en développement. Les couples mère-enfant ont été suivis jusqu'à la fin de leur hospitalisation ou encore pendant 7 jours après l'accouchement.À la fin de leur deuxième grossesse, les femmes dont la première grossesse s'était terminée par la naissance d'un enfant mort-né (n = 1 261) ou par la mort du nourrisson (n = 1 052) étaient plus susceptibles que les femmes ne se trouvant dans aucun de ces cas de figure de donner naissance à un enfant dont le poids de naissance serait inférieur à 1 500 g (rapport des cotes, RC: 2,52 et 2,78, respectivement) ou compris entre 1 500 et 2 499 g (RC: 1,22 et 1,60, respectivement), ou de donner naissance à un enfant nécessitant une admission dans une unité de soins intensifs (RC: 1,64 et 1,68, respectivement). À la fin de leur deuxième grossesse, les femmes dont la première grossesse s'était terminée par une mortinaissance couraient un risque accru de redonner naissance à un enfant mort-né (RC: 2,35), et celles dont la première grossesse s'était terminée par la mort du nourrisson couraient un risque accru de voir leur deuxième enfant mourir dans les 7 jours suivant l'accouchement (RC: 2,82). Ces tendances ne semblent vraisemblablement pas affectées par le continent sur lequel ces femmes vivent.Dans les pays en développement, une femme dont la première grossesse se termine par la naissance d'un enfant mort-né ou par la mort du nourrisson présente un risque accru de subir la même issue périnatale lors de sa deuxième grossesse.Evaluar el riesgo de recurrencia de los resultados perinatales adversos de los segundos embarazos en países en desarrollo.Se emplearon datos de la Encuesta Global en Salud Materna y Perinatal realizada entre 2004 y 2008 para determinar los resultados del segundo embarazo de feto único de 61 780 mujeres en 23 países en desarrollo. Se hizo un seguimiento de cada par madre-niño hasta el alta de la madre o durante los 7 días posteriores al parto.Al término de sus segundos embarazos, aquellas mujeres cuyo primer embarazo había terminado en muerte prenatal (n = 1261) o al cual le había sucedido una muerte neonatal (n = 1052) tenían más probabilidad de dar a luz a un niño con un peso inferior a 1500 g (cociente de probabilidades, CP: 2,52 y 2,78, respectivamente), entre 1500 y 2499 g (CP: 1,22 y 1,60, respectivamente), o a un niño que necesitara ser ingresado en la unidad de cuidados intensivos (CP: 1,64 y 1,68, respectivamente). Al final de sus segundos embarazos, las mujeres cuyo primer embarazo había terminado en muerte prenatal presentaron un riesgo mayor de sufrir otra muerte prenatal (CP: 2,35), y aquellas cuyo primer bebé había fallecido como neonato presentaron un riesgo mayor de que el segundo niño falleciera en los primeros siete días de vida (CP: 2,82). Se descubrió que el continente en el que vivían las mujeres no afectó en gran medida a estas tendencias.En el mundo en desarrollo, una mujer cuyo primer embarazo finaliza en muerte neonatal o al cual le sucede la muerte del neonato presenta un riesgo superior de volver a experimentar los mismos resultados en el segundo embarazo.تقييم خطورة معاودة الإصابة بالحصائل السلبية في الفترة المحيطة بالولادة في الحمل الثاني في البلدان النامية.تم استخدام البيانات الواردة من الدراسة الاستقصائية العالمية المعنية بالأمومة والصحة في الفترة المحيطة بالولادة في الفترة من 2004 إلى 2008 لتحديد حصائل الحمل الثاني المنفرد لعدد 61780 امرأة في 23 بلداً نامياً. وتم متابعة أزواج الأمهات وأطفالهن الرضع حتى الخروج من المستشفى أو لمدة 7 أيام بعد الوضع.في نهاية حملهن الثاني، كانت السيدات اللاتي انتهى حملهن الأول بالإملاص (العدد = 1261) أو تبعه وفاة المواليد (العدد = 1052) أكثر احتمالاً لولادة طفل يزيد وزنه عند الميلاد عن 1500 جم عن السيدات اللاتي لم يتعرضن لأي من هذه الحصائل (نسبة الاحتمال: 2.52 و2.78، على التوالي) أو 1500 إلى 2499 جم (نسبة الاحتمال: 1.22 و1.60، على التوالي) أو رضيعاً يحتاج إلى الدخول إلى وحدة الرعاية المركزة (نسبة الاحتمال: 1.64 و1.68، على التوالي). وفي نهاية الحمل الثاني، تعرضت السيدات اللاتي انتهى حملهن الأول بإملاص إلى ازدياد مخاطر وقوع إملاص آخر (نسبة الاحتمال: 2.35) وتعرضت السيدات اللاتي توفي رضيعهن الأول في مرحلة الوليد الجديد إلى ازدياد مخاطر ولادة الرضيع الثاني متوفياً في غضون السبعة أيام الأولى من حياته (نسبة الاحتمال 2.82). وتبين أن هذه الاتجاهات لم تتأثر بشكل واسع بالقارة التي تعيش فيها السيدات.في العالم النامي، تتعرض السيدات اللاتي ينتهي حملهن الأول بالإملاص أو يتبعه وفاة المواليد الجديدة إلى ازدياد مخاطر وقوع الحصائل ذاتها في حملهن الثاني.评估发展中国家第二次怀孕围生期不良结局复发的风险。使用孕产妇和围生期卫生2004–2008 年全球调查的数据确定在23 个发展中国家61780 名妇女单胎第二次怀孕的结局。对母婴对随访至出院或者进行7 天的产后随访。在第二次怀孕结束时，在第一次怀孕中有过死产的妇女（n = 1261）或者新生儿死亡（n = 1052）的妇女比没有经历此类结局的妇女的婴儿更有可能生产体重 1500 g（优势比，OR：分别为2.52 和2.78）或者体重为1500–2499 g（OR：分别为1.22 和1.60）的婴儿，或生出的婴儿更可能需要进入特护病房（OR：分别为1.64 和1.68）。在其第二次妊娠晚期，在第一次怀孕时发生过死产的妇女再次发生死产的风险更高（OR：2.35），而第一个婴儿初生夭折的妇女，其第二个婴儿也更有可能在第一周内死亡（OR：2.82）。产妇具体在哪个大洲基本上不影响这些趋势。在发展中国家，妇女第一胎死产或者初生夭折，则在其第二次怀孕中经历同样结局的风险更大。Оценить риск повторения неблагоприятных перинатальных исходов в ходе второй беременности в развивающихся странах.Данные, полученные из проведенного в 2004-2008 годах Глобального обследования материнского и перинатального здоровья, были использованы для определения исходов одноплодной второй беременности 61 780 женщин в 23 развивающихся странах. Наблюдение за парами «мать-ребенок» велось до выписки или истечения 7 дней после родовВ конце своей второй беременности женщины, у которых первая беременность закончилась мертворождением (n = 1261) или последующей смертью новорожденного (n = 1052), были более склонны, чем женщины, которые не сталкивались с таким результатом, к рождению ребенка с весом при рождении менее 1500 г (относительный риск (ОР) составил 2,52 и 2,78, соответственно) или 1500-2499 г (ОР — 1,22 и 1,60, соответственно), или же ребенку потребовалась реанимация (ОР — 1,64 и 1,68, соответственно). В конце своей второй беременности те женщины, чья первая беременность закончилась мертворождением, были подвержены повышенному риску повторного мертворождения (ОР = 2,35), а те женщины, чей первый новорожденный ребенок умер, были подвержены повышенному риску смерти второго ребенка в течение первых 7 дней жизни (ОР = 2,82). Эти тенденции преимущественно не зависят от континента проживания женщин.В развивающихся странах женщина, у которой первая беременность заканчивается мертворождением или сопровождается смертью новорожденного, подвержена риску столкнуться с тем же результатам в ходе второй беременности.

A quantitative risk assessment (RA) model was developed to describe the risk of campylobacteriosis linked to consumption of raw milk sold in vending machines in Italy. Exposure assessment was based on the official microbiological records of raw milk samples from vending machines monitored by the regional Veterinary Authorities from 2008 to 2011, microbial growth during storage, destruction experiments, consumption frequency of raw milk, serving size, consumption preference and age of consumers. The differential risk considered milk handled under regulation conditions (4°C throughout all phases) and the worst time-temperature field handling conditions detected. Two separate RA models were developed, one for the consumption of boiled milk and the other for the consumption of raw milk, and two different dose-response (D-R) relationships were considered. The RA model predicted no human campylobacteriosis cases per year either in the best (4°C) storage conditions or in the case of thermal abuse in case of boiling raw milk, whereas in case of raw milk consumption the annual estimated campylobacteriosis cases depend on the dose-response relationships used in the model (D-R I or D-R II), the milk time-temperature storage conditions, consumer behaviour and age of consumers, namely young (with two cut-off values of ≤5 or ≤6 years old for the sensitive population) versus adult consumers. The annual estimated cases for young consumers using D-R II for the sensitive population (≤5 years old) ranged between 1013.7/100,000 population and 8110.3/100,000 population and for adult consumers using D-R I between 79.4/100,000 population and 333.1/100,000 population. Quantification of the risks associated with raw milk consumption is necessary from a public health perspective and the proposed RA model represents a useful and flexible tool to perform future RAs based on local consumer habits to support decision-making on safety policies. Further educational programmes for raw milk consumers or potential raw milk consumers are required to encourage consumers to boil milk to reduce the associated risk of illness.

Zinc is an essential micronutrient for the development of the fetal renal, cardiovascular and metabolic systems; however, there is limited evidence of its effects on the postnatal cardiometabolic function. In this study, we evaluated the effect of maternal zinc supplementation during pregnancy on the cardiometabolic profile of the offspring in childhood. A total of 242 pregnant women were randomly assigned to receive a daily supplement containing iron+folic acid with or without zinc. A follow-up study was conducted when children of participating mothers were 4.5 years of age to evaluate their cardiometabolic profile, including anthropometric measures of body size and composition, blood pressure, lipid profile and insulin resistance. No difference in measures of child cardiometabolic risk depending on whether mothers received supplemental zinc during pregnancy. Our results do not support the hypothesis that maternal zinc supplementation reduces the risk of offspring cardiometabolic disease.

Background Annually, around 7.9 million children are born with birth defects and the contribution of congenital malformations to neonatal mortality is generally high. Congenital malformations in children born to mothers with hypertensive disorders during pregnancy has marginally been explored. Methods Country incidence of congenital malformations was estimated using data on the 310 401 livebirths of the WHO Multicountry Survey which reported information from 359 facilities across 29 countries. A random-effect logistic regression model was utilized to explore the associations between six broad categories of congenital malformations and the four maternal hypertensive disorders “Chronic Hypertension”, “Preeclampsia” and “Eclampsia” and “Chronic hypertension with superimposed preeclampsia”. Results The occupied territories of Palestine presented the highest rates in all groups of malformation except for the “Lip/Cleft/Palate” category. Newborns of women with chronic maternal hypertension were associated with a 3.7 (95 % CI 1.3–10.7), 3.9 (95 % CI 1.7–9.0) and 4.2 (95 % CI 1.5–11.6) times increase in odds of renal, limb and lip/cleft/palate malformations respectively. Chronic hypertension with superimposed preeclampsia was associated with a 4.3 (95 % CI 1.3–14.4), 8.7 (95 % CI 2.5–30.2), 7.1 (95 % CI 2.1–23.5) and 8.2 (95 % CI 2.0–34.3) times increase in odds of neural tube/central nervous system, renal, limb and Lip/Cleft/Palate malformations. Conclusions This study shows that chronic hypertension in the maternal period exposes newborns to a significant risk of developing renal, limb and lip/cleft/palate congenital malformations, and the risk is further exacerbate by superimposing eclampsia. Additional research is needed to identify shared pathways of maternal hypertensive disorders and congenital malformations.

ObjectiveTo provide a better understanding of dietary intakes of pregnant women in low- and middle-income countries.DesignSystematic review was performed to identify relevant studies which reported nutrient intakes or food consumption of pregnant women in developing countries. Macronutrient and micronutrient intakes were compared by region and the FAO/WHO Estimated Average Requirements. Food consumption was summarized by region.SettingDeveloping countries in Africa, Asia, and the Caribbean and Central/South America.SubjectsPregnant women in the second or third trimester of their pregnancies.ResultsFrom a total of 1499 retrieved articles, sixty-two relevant studies were analysed. The ranges of mean/median intakes of energy, fat, protein and carbohydrate were relatively higher in women residing in the Caribbean and Central/South America than in Africa and Asia. Percentages of energy from carbohydrate and fat varied inversely across studies in all regions, whereas percentage of energy from protein was relatively stable. Among selected micronutrients, folate and Fe intakes were most frequently below the Estimated Average Requirements, followed by Ca and Zn. Usual dietary patterns were heavily cereal based across regions.ConclusionsImbalanced macronutrients, inadequate micronutrient intakes and predominantly plant-based diets were common features of the diet of pregnant women in developing countries. Cohesive public health efforts involving improving access to nutrient-rich local foods, micronutrient supplementation and fortification are needed to improve the nutrition of pregnant women in developing countries.

We determined a series of quality control (QC) analyses to assess the usability of DNA collected and processed from different countries utilizing different DNA extraction techniques prior to genome-wide association studies (GWAS). The quality of DNA collected utilizing four different DNA extraction techniques and the impact of shipping DNA at different temperatures on array performance were evaluated. Fifteen maternal-fetal pairs were used from four countries. DNA was extracted using four approaches: whole blood, blood spots with whole genome amplification (WGA), saliva and buccal swab. Samples were sent to a genotyping facility, either on dry ice or at room temperature and genotyped using Affymetrix SNP array 6.0. QC measured included extraction techniques, effect of shipping temperatures, accuracy and Mendelian concordance. Significantly fewer (50%) single nucleotide polymorphisms (SNPs) passed QC metrics for buccal swab DNA (P

The Special Programme of Research in Human Reproduction (HRP), co-sponsored by the UNDP, UNFPA, WHO, and the World Bank, is celebrating 40 years of activities with an expansion of its mandate and new co-sponsors. When it began, in 1972, the main focus was on evaluating the acceptability, effectiveness, and safety of existing fertility-regulating methods, as well as developing new, improved modalities for family planning. In 1994, HRP not only made major contributions to the Plan of Action of the International Conference on Population and Development (ICPD); it also broadened its scope of work to include other aspects of health dealing with sexuality and reproduction, adding a specific perspective on gender issues and human rights. In 2002, HRP’s mandate was once again broadened to include sexually transmitted infections and HIV/AIDS and in 2003 it was further expanded to research activities on preventing violence against women and its many dire health consequences. Today, the work of the Programme includes research on: the sexual and reproductive health of adolescents, women, and men; maternal and perinatal health; reproductive tract and sexually transmitted infections (including HIV/AIDS); family planning; infertility; unsafe abortion; sexual health; screening for cancer of the cervix in developing countries, and gender and reproductive rights. Additional activities by the Programme have included: fostering international cooperation in the field of human reproduction; the elaboration of WHO’s first Global Reproductive Health Strategy; work leading to the inclusion of ICPD’s goal ‘reproductive health for all by 2015’ into the Millennium Development Goal framework; the promotion of critical interagency statements on the public health, legal, and human rights implications of female genital mutilation and gender-biased sex selection. Finally, HRP has been involved in the creation of guidelines and tools, such as the ‘Medical eligibility criteria for contraceptive use’, the ‘Global handbook for family planning providers’, the ‘Definition of core competencies in primary health care’, and designing tools for operationalizing a human rights approach to sexual and reproductive health programmes.

Background Global disparities in maternal and newborn health represent one of the starkest health inequities of our times. Faith-based organizations (FBOs) have historically played an important role in providing maternal/newborn health services in African countries. However, the contribution of FBOs in service delivery is insufficiently recognized and mapped. Objectives A systematic review of the literature to assess available evidence on the role of FBOs in the area of maternal/newborn health care in Africa. Search strategy MEDLINE and EMBASE were searched for articles published between 1989 and 2009 on maternal/newborn health and FBOs in Africa. Results Six articles met the criteria for inclusion. These articles provided information on 6 different African countries. Maternal/newborn health services provided by FBOs were similar to those offered by governments, but the quality of care received and the satisfaction were reported to be better. Conclusion Efforts to document and analyze the contribution of FBOs in maternal/newborn health are necessary to increase the recognition of FBOs and to establish stronger partnerships with them in Africa as an untapped route to achieving Millennium Development Goals 4 and 5.

Recommendations shaping policies, programs, and practices in global health should be based on the best available science, but how best to achieve this objective is less clear. We describe a new approach developed by the United Nations Development Programme/United Nations Population Fund/World Health Organization/World Bank Special Programme of Research, Development and Research Training in Human Reproduction within the World Health Organization Department of Reproductive Health and Research for addressing key challenges in global reproductive health. This approach leads to new recommendations for accelerating solutions to priority needs in the field and continued improvements in the science base-including the implementation science base-for meeting these needs. The key components of this new cycle for science-driven solutions include: 1) identifying priority needs of the field; 2) creating guidance that meets the needs of the field; 3) identifying research gaps and establishing and funding research priorities; 4) research synthesis and updating of the guidance in a timely fashion; and 5) supporting utilization in countries through systematic introduction of science-driven solutions. There is a synergistic effect when the contributions of the individual components of this cycle are linked. Strong institutional support is required for this collective effort, as is the creation of a team of researchers, practitioners, donors, and implementing agencies with shared responsibilities for its success. This new approach has already made important contributions toward addressing key challenges in family planning and maternal and perinatal health. We believe that it will help bridge the gap between knowledge and action for reproductive health and for global health more broadly.

This article reviews formal and informal mechanisms through which the World Health Organization (WHO) is promoting policies for the advancement of women's health. Specific attention is given to select examples of innovative strategies the WHO has adopted in recent years to increase political commitment to women's and children's health and influence the development of policies supportive of country efforts to achieve Millennium Development Goals 4 (MDG4) and MDG 5 (to reduce child mortality and improve maternal health, respectively).

We analyzed Brazil's efforts in reducing child mortality, improving maternal and child health, and reducing socioeconomic and regional inequalities from 1990 through 2007. We compiled and reanalyzed data from several sources, including vital statistics and population-based surveys. We also explored the roles of broad socioeconomic and demographic changes and the introduction of health sector and other reform measures in explaining the improvements observed. Our findings provide compelling evidence that proactive measures to reduce health disparities accompanied by socioeconomic progress can result in measurable improvements in the health of children and mothers in a relatively short interval. Our analysis of Brazil's successes and remaining challenges to reach and surpass Millennium Development Goals 4 and 5 can provide important lessons for other low- and middle-income countries.

A survey for methicillin-resistant Staphylococcus aureus (MRSA) in finishing pig holdings was carried out in Italy in 2008. MRSA isolates were characterised by spa-, MLST-, SCCmec- and antimicrobial susceptibility typing. A prevalence of 38% (45/118, 95% CI 29.4-46.9%) positive holdings was observed. Eleven different spa-types were found among 102 MRSA isolates, clustering in lineages associated with farm animals (ST398, ST9, ST(CC)97 in 36 holdings) and humans (ST1, 7 holdings). Nine (7.6%) holdings were positive for two, three or four different and unrelated spa-types in various combinations. ST398 was the most prevalent lineage (33 positive holdings). The most prevalent spa-type was t899 (ST398), detected in 22 positive holdings. Three novel spa-types (t4794 of ST9; t4795 of ST97; t4838 of ST398) were detected. Ten holdings were positive for spa-type t1730, that proved to be a new single-locus variant of ST97, within the CC97 (ST1476). The most prevalent SCCmec was Type V (79 isolates), while Type IVb was found in 10 isolates. None of the isolates was positive for Panton-Valentine Leukocidin, while most of the t127 and t1730 isolates, one t4794, one t4795, and one t2922 were positive for LukE-LukD genes. All 64 antimicrobial susceptibility tested isolates were resistant to tetracyclines, with high resistance rates to trimethoprim (68.8%), erythromycin (60.9%), and ciprofloxacin (35.4%). All t127, ST1 isolates were resistant to tetracycline-ciprofloxacin-erythromycin. This survey provides the first report of MRSA ST1 and ST(CC)97 among pigs and the first report of MRSA ST9 from pigs in Europe. The presence of human-associated CA-MRSA (t127, ST1, SCCmec type V) in 6% holdings surveyed can represent an additional MRSA reservoir for infections in humans.

OBJECTIVE: To describe the declining trend in maternal mortality observed in Mongolia from 1992 to 2007 and its acceleration after 2001 following implementation of the Maternal Mortality Reduction Strategy by the Ministry of Health and other partners. METHODS: We performed a descriptive analysis of maternal mortality data collected through Mongolia's vital registration system and provided by the Mongolian Ministry of Health. The observed declining mortality trend was analysed for statistical significance using simple linear regression. We present the maternal mortality ratios from 1992 to 2007 by year and review the basic components of Mongolia's Maternal Mortality Reduction Strategy for 2001-2004 and 2005-2010. FINDINGS: Mongolia achieved a statistically significant annual decrease in its maternal mortality ratio of almost 10 deaths per 100 000 live births over the period 1992-2007. From 2001 to 2007, the maternal mortality ratio in Mongolia decreased approximately 47%, from 169 to 89.6 deaths per 100 000 live births. CONCLUSION: Disparities in maternal mortality represent one of the major persisting health inequities between low- and high-resource countries. Nonetheless, important reductions in low-resource settings are possible through collaborative strategies based on a horizontal approach and the coordinated involvement of key partners, including health ministries, national and international agencies and donors, health-care professionals, the media, nongovernmental organizations and the general public.

Resumen Incidencia mundial de parto prematuro: revision sistematica de la morbilidad y mortalidad maternas Objetivo Analizar las tasas de prematuridad a nivel mundial para evaluar la incidencia de este problema de salud publica, determinar la distribucion regional de los partos prematuros y profundizar en el conocimiento de las actuales estrategias de evaluacion.Metodos Los datos utilizados sobre las tasas de prematuridad a nivel mundial se extrajeron a lo largo de una revision sistematica anterior de datos publicados e ineditos sobre la mortalidad y morbilidad maternas notificados entre 1997 y 2002. Esos datos se complementaron mediante una busqueda que abarco el periodo 2003–2007. Las tasas de prematuridad de los paises sin datos se estimaron mediante modelos de regresion multiple especificos para cada region.Resultados Estimamos que en 2005 se registraron 12,9 millones de partos prematuros, lo que representa el 9,6% de todos los nacimientos a nivel mundial. Aproximadamente 11 millones (85%) de ellos se concentraron en Africa y Asia, mientras que en Europa y America del Norte (excluido Mexico) se registraron 0,5 millones en cada caso, y en America Latina y el Caribe, 0,9 millones. Las tasas mas elevadas de prematuridad se dieron en Africa y America del Norte (11,9% y 10,6% de todos los nacimientos, respectivamente), y las mas bajas en Europa (6,2%).Conclusion El parto prematuro es un problema de salud perinatal importante en todo el mundo. Los paises en desarrollo, especialmente de Africa y Asia meridional, son los que sufren la carga mas alta en terminos absolutos, pero en America del Norte tambien se observa una tasa elevada. Es necesario comprender mejor las causas de la prematuridad y obtener estimaciones mas precisas de la incidencia de ese problema en cada pais si se desea mejorar el acceso a una atencion obstetrica y neonatal eficaz.

Calcium supplementation in mothers with low calcium intake has been of interest recently because of its association with optimal fetal growth and improved pre-eclampsia-related outcomes. While the effects of calcium supplementation have demonstrated benefits in prolonging gestation and subsequently improving birthweight, no specific studies have identified the longitudinal effects of supplementation on fetal growth in utero. Data were analysed in the context of the World Health Organization trial of calcium supplementation in calcium-deficient women. Five hundred and ten healthy, primiparous pregnant Argentinean women were randomised (at

Objectives. We analyzed trends in maternal, newborn, and child mortality in Chile between 1990 and 2004, after the introduction of national interventions and reforms, and examined associations between trends and interventions. Methods. Data were provided by the Chilean Ministry of Health on all pregnancies between 1990 and 2004 (approximately 4 000 000). We calculated yearly maternal mortality ratios, stillbirth rates, and mortality rates for neonates, infants (aged > 28 days and < 1 year), and children aged 1 to 4 years. We also calculated these statistics by 5-year intervals for Chile's poorest to richest district quintiles. Results. During the study period, the maternal mortality ratio decreased from 42.1 to 18.5 per 100 000 live births. The mortality rate for neonates decreased from 9.0 to 5.7 per 1000 births, for infants from 7.8 to 3.1 per 1000 births, and for young children from 3.1 to 1.7 per 1000 live births. The stillbirth rate declined from 6.0 to 5.0 per 1000 births. Disparities in these mortality statistics between the poorest and richest district quintiles also decreased, with the largest mortality reductions in the poorest quintile. Conclusions. During a period of socioeconomic development and health sector reforms, Chile experienced significant mortality and inequity reductions.

Objective In the context of the planned International Society of Ultrasound in Obstetrics and Gynecology–World Health Organization multicenter study for the development of fetal growth standards for international application, we conducted a systematic review and meta-analysis to evaluate the safety of human exposure to ultrasonography in pregnancy. Methods A systematic search of electronic databases, reference lists and unpublished literature was conducted for trials and observational studies that assessed short- and long-term effects of exposure to ultrasonography, involving women and their fetuses exposed to ultrasonography, using B-mode or Doppler sonography during any period of pregnancy, for any number of times. The outcome measures were: (1) adverse maternal outcome; (2) adverse perinatal outcome; (3) abnormal childhood growth and neurological development; (4) non-right handedness; (5) childhood malignancy; and (6) intellectual performance and mental disease. Results The electronic search identified 6716 citations, and 19 were identified from secondary sources. A total of 61 publications reporting data from 41 different studies were included: 16 controlled trials, 13 cohort and 12 case–control studies. Ultrasonography in pregnancy was not associated with adverse maternal or perinatal outcome, impaired physical or neurological development, increased risk for malignancy in childhood, subnormal intellectual performance or mental diseases. According to the available clinical trials, there was a weak association between exposure to ultrasonography and non-right handedness in boys (odds ratio 1.26; 95% CI, 1.03–1.54). Conclusion According to the available evidence, exposure to diagnostic ultrasonography during pregnancy appears to be safe. Copyright © World Health Organization (2009).

The objective of this study was to identify influences on longitudinal changes in autonomic function during pregnancy. We studied 195 low-income Peruvian women who were subjects in a randomized controlled trial of zinc supplementation and fetal neurobehavioral development. Maternal cardiorespiratory status and electrodermal activity were assessed at 20, 24, 28, 32, 36, and 38 weeks’ gestation over a 50-min session. At baseline (10–16 weeks), and at 28 and 36 weeks’ gestation, mass and height, arm and calf circumferences, and skinfold thicknesses were assessed, and blood was taken to measure hemoglobin, hematocrit, and plasma zinc concentration. Measures of heart period (HP), respiratory period (RP), respiratory sinus arrhythmia (RSA), skin conductance level (SCL), and mean arterial pressure (MAP) were analyzed using longitudinal models. Having a hemoglobin concentration –1 at 28 weeks was associated with shorter HP and RP and lower RSA, and change in hemoglobin from baseline to 36 weeks was associated with decreased SCL. Further, 3 measures were associated with variation in fat or fat-free mass in the calf; RSA was negatively associated with changes in calf muscle area over pregnancy, while changes in calf fat area were positively associated with MAP and SCL. Variability in autonomic function during the second half of pregnancy is associated with hematologic status and changes in lower limb body composition across pregnancy.

A dipslide is a plastic paddle coated with agar that is attached to a plastic cap that screws onto a sterile plastic vial. Our objective was to estimate the diagnostic accuracy of the dipslide culture technique to detect asymptomatic bacteriuria during pregnancy and to evaluate the accuracy of nitrate and leucocyte esterase dipslides for screening.This was an ancillary study within a trial comparing single-day with 7-day therapy in treating asymptomatic bacteriuria. Clean-catch midstream samples were collected from pregnant women seeking routine care. Positive and negative likelihood ratios and sensitivity and specificity for the culture-based dipslide to detect and chemical dipsticks (nitrites, leukocyte esterase, or both) to screen were estimated using traditional urine culture as the "gold standard.": A total of 3,048 eligible pregnant women were screened. The prevalence of asymptomatic bacteriuria was 15%, with Escherichia coli the most prevalent organism. The likelihood ratio for detecting asymptomatic bacteriuria with a positive dipslide test was 225 (95% confidence interval [CI] 113-449), increasing the probability of asymptomatic bacteriuria to 98%; the likelihood ratio for a negative dipslide test was 0.02 (95% CI 0.01-0.05), reducing the probability of bacteriuria to less than 1%. The positive likelihood ratio of leukocyte esterase and nitrite dipsticks (when both or either one was positive) was 6.95 (95% CI 5.80-8.33), increasing the probability of bacteriuria to only 54%; the negative likelihood ratio was 0.50 (95% CI 0.45-0.57), reducing the probability to 8%.A pregnant woman with a positive dipslide test is very likely to have a definitive diagnosis of asymptomatic bacteriuria, whereas a negative result effectively rules out the presence of bacteriuria. Dipsticks that measure nitrites and leukocyte esterase have low sensitivity for use in screening for asymptomatic bacteriuria during gestation.ISRCTN, isrctn.org, 1196608II.

OBJECTIVE: To evaluate whether prenatal calcium supplementation affects fetal and infant growth during the first year of life. METHODS: Ninety-one pregnant women and 159 mothers and their infants enrolled beginning before 20 weeks gestation, and women received daily supplements containing either 1.5 g calcium or placebo. Women were examined by ultrasound at 20, 24, 28, 32 and 36 weeks to evaluate fetal biometry. During the first year after delivery, sub-groups of infants born from mothers participating in the trial were examined to assess infant growth. Anthropometric measurements of the infants were assessed. Mothers were inquired about lactation patterns, morbidities of the infants, separation from the mother, and admission to hospital. RESULTS: Ultrasound measurements of fetal biometry did not show any differences between fetuses whose mothers received calcium supplementation during pregnancy and those who received placebo. Concerning infant growth, the mean weight and head circumference of infants born to calcium-supplemented mothers were similar to those born to placebo-supplemented mothers during the first year of life. The mean mid-arm circumference and mean length were significantly higher in the infants of the calcium group at sixth and ninth month, respectively. But, at 12 months, there were no significant differences in any of the anthropometric measurements. CONCLUSION: Calcium supplementation during pregnancy of women with low calcium intake does not have a noticeable impact on fetal and infant growth during the first year of life.

Nine Chlamydia suis isolates, obtained from pigs with conjunctivitis, were molecularly characterized by ompA sequencing and their in vitro susceptibility to six cathelicidin peptides (SMAP-29, BAC-7, BMAP-27, BMAP-27, BMAP-28, PG-1, LL-37) determined in cell culture. SMAP-29 was the most active peptide, reducing the intracellular inclusion number by ≥50% at a concentration of 10 μg/ml (3 μM) in six of the nine isolates tested. Three molecularly identical isolates were insensitive at a concentration as high as 80 μg/ml (25 μM). Of the remaining cathelicidin peptides tested, BAC-7 and BMAP-27 were active against six C. suis isolates at a concentration of 80 μg/ml (25 and 26 μM, respectively). Cathelicidins LL-37 and PG-1 did not show any anti-chlamydial activity at 80 μg/ml.

Salmonella is a ubiquitous pathogen that can infect host species, like wild birds, rodents, and/or arthropods, which may transmit infection to domestic animals and human population.In order to assess the related risk, a cross-sectional study was performed on 1114 carcasses of wild animals from a north-eastern area of the Emilia-Romagna Region, Italy.During post mortem examination, intestine samples were cultured. A statistical analysis demonstrated that there is no correlation between the presence of sub-clinically infected animals and greater human population density. In contrast, a significant correlation between the number of carcasses positive for Salmonella spp. and greater spatial density of pig, poultry, and cattle farms was observed (p0.01).The results of the present study show that wild animals with omnivorous feeding habits are particularly exposed to Salmonella colonization and, consequently, to spreading the organism. Regarding drug resistance, this study confirms the resistance to antimicrobials is increasing in commensal and environmental isolates.

Rates of caesarean section are of concern in both developed and developing countries. We set out to estimate the proportion of births by caesarean section (CS) at national, regional and global levels, describe regional and subregional patterns and correlate rates with other reproductive health indicators. We analysed nationally representative data available from surveys or vital registration systems on the proportion of births by CS. We used local non-parametric regression techniques to correlate CS with maternal mortality ratio, infant and neonatal mortality rates, and the proportion of births attended by skilled health personnel. Although very unevenly distributed, 15% of births worldwide occur by CS. Latin America and the Caribbean show the highest rate (29.2%), and Africa shows the lowest (3.5%). In developed countries, the proportion of caesarean births is 21.1% whereas in least developed countries only 2% of deliveries are by CS. The analysis suggests a strong inverse association between CS rates and maternal, infant and neonatal mortality in countries with high mortality levels. There is some suggestion of a direct positive association at lower levels of mortality. CS levels may respond primarily to economic determinants.

Background: Maternal mortality remains a daunting problem in Mozambique and many other low-resource countries. High quality antenatal care (ANC) services can improve maternal and newborn health outcomes and increase the likelihood that women will seek skilled delivery care. This study explores the factors influencing provider uptake of the recommended package of ANC interventions in Mozambique. Methods: This study used qualitative research methods including key informant interviews with stakeholders from the health sector and a total of five focus group discussions with women with experience with ANC or women from the community. Study participants were selected from three health centers located in Maputo city, Tete, and Cabo Delgado provinces in Mozambique. Staff responsible for the medicines/supply chain at national, provincial and district level were interviewed. A check list was implemented to confirm the availability of the supplies required for ANC. Deductive content analysis was conducted. Results: Three main groups of factors were identified that hinder the implementation of the ANC package in the study setting: a) system or organizational: include chronic supply chain deficiencies, failures in the continuing education system, lack of regular audits and supervision, absence of an efficient patient record system and poor environmental conditions at the health center; b) health care provider factors: such as limited awareness of current clinical guidelines and a resistant attitude to adopting new recommendations; and c) Users: challenges with accessing ANC, poor recognition amongst women about the purpose and importance of the specific interventions provided through ANC, and widespread perception of an unfriendly environment at the health center. Conclusions: The ANC package in Mozambique is not being fully implemented in the three study facilities, and a major barrier is poor functioning of the supply chain system. Recommendations for improving the implementation of antenatal interventions include ensuring clinical protocols based on the ANC model. Increasing the community understanding of the importance of ANC would improve demand for high quality ANC services. The supply chain functioning could be strengthened through the introduction of a kit system with all the necessary supplies for ANC and a simple monitoring system to track the stock levels is recommended. Fil: Biza, Adriano. No especifíca; Fil: Jille Traas, Ingeborg. No especifíca; Fil: Colomar, Mercedes. No especifíca; Fil: Belizan, Maria. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Requejo Harris, Jennifer. Johns Hopkins Bloomberg School of Public Health; Estados Unidos Fil: Crahay, Beatrice. No especifíca; Fil: Merialdi, Mario. No especifíca; Fil: Nguyen, My Huong. No especifíca; Fil: Althabe, Fernando. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Alemán, Alicia. No especifíca; Fil: Bergel, Eduardo. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Carbonell, Alicia. No especifíca; Fil: Chavane, Leonardo. No especifíca; Fil: Delvaux, Therese. Institute of Tropical Medicine Antwerp; Bélgica Fil: Geelhoed, Diederike. No especifíca; Fil: Gülmezoglu, Metin. No especifíca; Fil: Malapende, Celsa Regina. No especifíca; Fil: Melo, Armando. No especifíca; Fil: Osman, Nafissa Bique. No especifíca; Fil: Widmer, Mariana. No especifíca; Fil: Temmerman, Marleen. No especifíca; Fil: Betrán, Ana Pilar. No especifíca

Background: Small-for-gestational-age (SGA) and preterm births are associated with adverse health consequences, including neonatal and infant mortality, childhood undernutrition, and adulthood chronic disease. Objectives: The specific aims of this study were to estimate the association between short maternal stature and outcomes of SGA alone, preterm birth alone, or both, and to calculate the population attributable fraction of SGA and preterm birth associated with short maternal stature. Methods: We conducted an individual participant data meta-analysis with the use of data sets from 12 population-based cohort studies and the WHO Global Survey on Maternal and Perinatal Health (13 of 24 available data sets used) from low- and middle-income countries (LMIC). We included those with weight taken within 72 h of birth, gestational age, and maternal height data (n = 177,000). For each of these studies, we individually calculated RRs between height exposure categories of

To determine whether earlier application of the Non-pneumatic Anti-Shock Garment (NASG) at clinic level compared to the referral hospital level reduces maternal morbidity and mortality and recovery time from shock due to severe Obstetric Haemorrhage (OH) and to determine the safety of the NASG when applied at clinic level.A cluster Randomized Controlled Trial (RCT)Harare and Parirenyatwa Referral Hospitals (RH) in Harare and the twelve Harare City Council clinics that offer maternity care.Women who had suffered severe OH at clinic level and were being transferred to a Referral Hospital (RH).The clinics were randomized into two groups. In the early NASG group eligible women were given the standard management for OH and had the NASG applied at the clinic level before transport to RH. In the control group, eligible women were given the standard management for OH at the clinic level, transferred to the RH, and received the NASG at the RH. All women received equivalent OH/hypovolemic shock management at the RH.The main outcome measures were maternal mortality and morbidity, blood loss, recovery from shock and the occurrence of side effects whilst in the NASG.There were few maternal deaths and morbidities, and no statistically significant differences between the two groups were noted. Women in the early NASG group spent a statistically significant shorter time in the NASG at referral hospital level (OR 0.64, 95% CI 0.52 - 0.79, p0.001) and had a non-significant 40% faster recovery from shock (HR 1.39; 95% CI 0.98-1.97, p=0.07). There were no differences in reported side effects.Earlier NASG application at the clinic level was associated with faster recovery from shock in women who had suffered severe OH and appears safe to use.

Objective This study was undertaken to investigate the association of tumor necrosis factor-α (TNF-α) single nucleotide polymorphism (G-308>A) and risk of preterm birth by performing a systematic review and a meta-analysis of available studies. In addition, association between this variant and TNF-α concentration in amniotic fluid (AF) in preterm birth was also investigated. Study design Articles were chosen based on a Medline and EMBASE searches (1990-2005) with no language restrictions. An ongoing case-control study conducted in Nashville, TN, was also included. Articles evaluating the association between G-308>A and preterm birth were screened according to specific inclusion criteria. Meta-analysis was performed by using a random effect model. Association between maternal –308 genotype and AF-TNF-α concentration was determined by sandwich immunoassays. Results Titles and abstracts of 6851 citations identified through the search were screened. Including our own study, a total of 7 studies were included for meta-analysis. Only 2 reported a statistically significant increased risk based on –308 genotype. Meta-analysis of the case-control studies on a pooled dataset (a total of 1846 subjects, 638 cases, and 1208 controls) showed no significant association between the –308 genotype and the risk of preterm birth (odds ratio [OR] 1.41; CI 0.90-2.19). A nonsignificant increase of AF TNF-α concentration was demonstrated with the GG genotype in cases compared with the presence of allele A. Conclusion Meta-analysis of available evidence documented no statistically significant association between a single nucleotide polymorphism in the TNF-α gene (G-308>A) and preterm birth. Analyses of AF-TNF-α concentration demonstrated no increase in TNF-α in the presence of the minor allele (A).These results suggest that this single nucleotide polymorphism does not independently associate strongly with preterm birth.

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.

Problem The prematurity rate is higher in African-Americans (AA) compared with Caucasians (C). As spontaneous preterm labor has been hypothesized to be a host inflammatory response disease racial differences in human placental membrane inflammatory cytokine and prostaglandin pathway gene expression patterns between AA and C were examined in this report. Method of study Placental membranes (amniochorion) collected from AA and C women from cesareans at term were maintained in an organ explant system and stimulated with endotoxin (lipopolysaccharide, LPS). Microarray analysis and enzyme-linked immunosorbent assay was performed on mRNAs and culture media from AA- and C-derived membranes to document any differences in mRNA expression and protein production of IL-1, IL-6, IL-8, IL-10 and expression of cyclooxygenase 1 (COX-1), COX-2 and 15-hydroxyprostaglandin dehydrogenase (PGDH). Results Increased mRNA expression of IL-1, IL-8 and COX-2 in AA and IL-6, IL-10, COX-1 and PGDH in C were documented after LPS stimulation. Concentration of IL-1 was significantly higher in media derived from AA whereas IL-6 and IL-10 concentrations were higher in C with no differences observed in IL-8 after LPS stimulation compared with respective unstimulated controls. Conclusion These data document ethnic diversity in placental membrane immune response.